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MP 1.03.01



Medical Policy    
Durable Medical Equipment
Original Policy Date

Last Review Status/Date
No routine review scheduled/5:2009

  Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.




An orthotic (orthosis) is a rigid or semi-rigid device used to support, restore, or protect body function. Orthotics may also redirect or restrict motion of an impaired body part.




Orthotic devices are considered medically necessary when prescribed by a qualified provider to be used for therapeutic support, protection, restoration, or function for an impaired body part.


Orthotic devices include:

  • braces for leg, arm, neck, back, and shoulder;
  • corsets for back or for use after special surgical procedures;
  • splints for extremities;
  • trusses.



Policy Guidelines

No applicable information



Benefit Application

BlueCard/National Account Issues

All medically necessary supplies, adjustment, repair, or replacement of covered orthotic devices are eligible for coverage. Replacement is provided usually after the device’s normal life span (wear and tear), malfunction of the device, and/or for growth adjustments. Plan contracts routinely exclude foot orthotics (custom-made functional and/or accommodating shoe inserts, fabricated for a specific individual from a model of a patient’s foot).


Other items that technically meet the definition of orthosis but that are often excluded by Plan contract language include:

  • arch supports;
  • elastic stockings and garter belts;
  • orthopedic shoes, unless one or both shoes are an integral part of a leg brace.




A search of the literature was completed through the MEDLINE database for the period of January 1990 through December 1995. The search strategy focused on references containing the following Medical Subject Heading:


– Orthotics

Research was limited to English-language journals on humans.







Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

ICD-9 Procedure 

No Code 


ICD-9 Diagnosis 


Code applicable diagnosis 



Cranial cervical orthotic, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated

  L0113 Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment
  L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200 Cervical, flexible (collar)
  L0210 Thoracic, rib belt
  L0220 Thoracic, rib belt, custom fabricated
   L0430 Spinal orthotic, anterior-posterior-lateral control, with interface material, custom fitted (DeWall Posture Protector only)
  L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0970, L0974, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment
  L0621, L0622, L0623, L0624 Sacroiliac orthotic (SO)
  L0625, L0626, L0627 Lumbar orthotic, flexible (LO)
  L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0972, L0976 Lumbar-sacral orthotic (LSO)
  L0700, L0710, L1000, L1001, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1120 Cervical-thoracic-lumbar-sacral orthosis (CTLSO)
  L0810, L0820, L0830 Halo procedure
  L0859 Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material
  L0861 Addition to halo procedure, replacement liner/interface material
  L0978 Axillary crutch extension
  L0980 Peroneal straps, pair
  L0982 Stocking supporter grips, set of 4
  L0984 Protective body sock, each
  L0999 Addition to spinal orthotic, not otherwise specified
  L1005 Tension based scoliosis orthotic and accessory pads, includes fitting and adjustment
  L1300 Other scoliosis procedure, body jacket molded to patient model
  L1310 Other scoliosis procedure, postoperative body jacket
  L1499 Spinal orthotic, not otherwise specified
  L1500, L1510, L1520 Thoracic-hip-knee-ankle orthotic (THKAO)
  L1600, L1610, L1620, L1630, L1640, L1650, L1652, L1660, L1680, L1685, L1686 Hip orthotic (HO)
  L1690 Combination, bilateral, lumbo-sacral, hip, femur orthotic providing adduction and internal rotation control, prefabricated, includes fitting and adjustment
  L1700 Legg Perthes orthotic, (Toronto type), custom fabricated
  L1710 Legg Perthes orthotic, (Newington type), custom fabricated
  L1720 Legg Perthes orthotic, trilateral, (Tachdijan type), custom fabricated
  L1730 Legg Perthes orthotic, (Scottish Rite type), custom fabricated
  L1755 Legg Perthes orthotic, (Patten bottom type), custom fabricated
  L1800, L1810, L1815, L1820, L1825, L1830, L1831, L1832, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1850, L1860 Knee orthotic (KO)
  L1900, L1901, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4396 Ankle-foot orthotic (AFO)
  L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136 Knee-ankle-foot orthotic (KAFO)
  L2040, L2050, L2060, L2070, L2080, L2090 Hip-knee-ankle-foot orthotic (HKAFO)
  L2180, L2182, L2184, L2186, L2188, L2190, L2192 Addition to lower extremity fracture orthotic
  L2200 Addition to lower extremity, limited ankle motion, each joint
  L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
  L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
  L2230 Addition to lower extremity, split flat caliper stirrups and plate attachment
  L2232 Addition to lower extremity orthotic, rocker bottom for total contact ankle-foot orthotic (AFO), for custom fabricated orthotic only
  L2240 Addition to lower extremity, round caliper and plate attachment
  L2250 Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
  L2260 Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)
  L2265 Addition to lower extremity, long tongue stirrup
  L2270 Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad
  L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
  L2280 Addition to lower extremity, molded inner boot
  L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
  L2310 Addition to lower extremity, abduction bar, straight
  L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated orthotic only
  L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthotic only
  L2335 Addition to lower extremity, anterior swing band
  L2340 Addition to lower extremity, pretibial shell, molded to patient model
  L2350 Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)
  L2360 Addition to lower extremity, extended steel shank
  L2370 Addition to lower extremity, Patten bottom
  L2375 Addition to lower extremity, torsion control, ankle joint and half solid stirrup
  L2380 Addition to lower extremity, torsion control, straight knee joint, each joint
  L2385 Addition to lower extremity, straight knee joint, heavy-duty, each joint
  L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot orthotic(KAFO), each joint
  L2390 Addition to lower extremity, offset knee joint, each joint
  L2395 Addition to lower extremity, offset knee joint, heavy-duty, each joint
  L2397 Addition to lower extremity orthotic, suspension sleeve
   L2405, L2415, L2425, L2430, L2492 Addition to knee joint
  L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550 Addition to lower extremity, thigh/weight bearing
  L2570, L2580, L2600, L2610, L2620, L2622, L2624, L2627, L2628, L2630, L2640, L2650 Addition to lower extremity, pelvic control
  L2660, L2670, L2680 Addition to lower extremity, thoracic control
  L2750 Addition to lower extremity orthotic, plating chrome or nickel, per bar
  L2755 Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only
  L2760 Addition to lower extremity orthotic, extension, per extension, per bar (for lineal adjustment for growth)
  L2768 Orthotic side bar disconnect device, per bar
  L2770, L2780, L2785, L2795 Addition to lower extremity orthotic
  L2800, L2810, L2820, L2830, L2830, L2850 Addition to lower extremity orthotic, knee controlorthotic only
  L2999 Lower extremity orthoses, not otherwise specified
   L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031 Foot insert
  L3040, L3050, L3060, L3070, L3080, L3090 Foot, arch support
  L3100 Hallus-valgus night dynamic splint
  L3140 Foot, abduction rotation bar, including shoes
  L3150 Foot, abduction rotation bar, without shoes
  L3160 Foot, adjustable shoe-styled positioning device
  L3170 Foot, plastic, silicone or equal, heel stabilizer, each
  L3201, L3202, L3203, L3204, L3206, L3207 Orthopedic shoe, (infant, child or junior) 
  L3208, L3209, L3211 Surgical boot, each, infant(child or junior)
  L3212, L3213, L3214 Benesch boot, pair, infant(child or junior) 
  L3215, L3216, L3217, L3224 Orthopedic footwear, ladies shoe
  L3219, L3221, L3222, L3225 Orthopedic footwear, mens shoe, oxford, each
  L3230 Orthopedic footwear, custom shoe, depth inlay, each
  L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
  L3251 Foot, shoe molded to patient model, silicone shoe, each
  L3252 Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each
  L3253 Foot, molded shoe, Plastazote (or similar), custom fitted, each
  L3254 Nonstandard size or width
  L3255 Nonstandard size or length
  L3257 Orthopedic footwear, additional charge for split size
  L3260 Surgical boot/shoe, each
  L3265 Plastazote sandal, each
  L3300, L3310, L3320, L3330, L3332, L3334 Lift, elevation, heel
  L3340, L3350 Heel wedge
  L3360, L3370 Sole wedge
  L3380 Clubfoot wedge
  L3390 Outflare wedge
  L3400, L3410 Metatarsal bar wedge
  L3420 Full sole and heel wedge, between sole
  L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3780, L3485 Heel (range)
  L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595 Orthopedic shoe addition
  L3600, L3610, L3620, L3630, L3640 Transfer of an orthotic from one shoe to another
  L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
  L3650, L3651, L3652, L3660, L3670, L3671, L3672, L3673, L3675, L3677 Shoulder orthotic (SO)
  L3700, L3701, L3702, L3710, L3720, L3730, L3740, L3760, L3762 Elbow orthotic (EO)
  L3763, L3764 Elbow-wrist-hand orthotic (EWHO)
  L3765, L3766 Elbow-wrist-hand-finger orthotic (EWHFO)
  L3806, L3807, L3808, L3900, L3901, L3904, , L3911, L3931 Wrist-hand-finger orthotic (WHFO)
  L3905, L3906, L3908, L3915 Wrist-hand orthotic (WHO)
  L3909 Wrist orthotic (WO), elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)
  L3912, L3913, L3921, L3923, L3929 Hand-finger orthotic (HFO), flexion glove with elastic finger control, prefabricated, includes fitting and adjustment
  L3917, L3919 Hand orthotic (HO)
  L3925, L3927, L3933, L3935 Finger orthotic (FO)
  L3956 Addition of joint to upper extremity orthotic, any material; per joint
   L3960, L3961, L3962, L3967, L3971, L3973, L3975. L3976, L3977, L3978 Shoulder-elbow-wrist-hand orthotic (SEWHO)
  L3964, L3965, L3966, L3968, L3969, L3970, L3972, L3974 Shoulder-elbow orthotic (SEO)
  L3980, L3982, L3984, L3995, L3999 Upper extremity fracture orthotic
  L4000, L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4392, L4394 Replacement accessories for various orthotics
  L4205, L4210 Repair of orthotic device
  L4350 Ankle control orthotic, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment
  L4360, L4386 Walking boot
  L4370 Pneumatic full leg splint, prefabricated, includes fitting and adjustment
  L4380 Pneumatic knee splint, prefabricated, includes fitting and adjustment
  L4398 Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment
  L8300, L8310, L8320, L8330 Truss






Devices, Orthotic



Policy History

Date Action Reason
11/30/96 Add to Durable Medical Equipment section New Policy
07/12/02 Replace Policy Policy reviewed without literature review; new review date only
04/29/03 Replace Policy Policy no longer scheduled for routine literature review.
05/06/09 Coding update only  added Truss codes to policy (L8300-L8330)


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