(DME), Prosthetics and Orthotics HCPCS Codes That Require Precertification

Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

************************************************************************************************************************** Please note that this list is not inclusive of all of the HCPCS codes that require precertification because of the $500 Allowance RULE which applies to DME, orthotics, equipment and supplies. However, codes list require precertification regardless of $500 RULE.

HCPCS QUEST Description A9274 X External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories A9277 X Transmitter, external, for use with interstitial continuous glucose monitoring system A9278 X Receiver (monitor); external, for use with interstitial continuous glucose monitoring system A9900 X Misc. DME supply, accessory, and/or service component of another HCPCS code A9999 X Misc. DME supply or accessory, not otherwise specific E0181 X Powered pressure reducing mattress overly/pad, alternating, with pump, includes heavy duty E0182 X Pump for alternating pressure pad, for replacement only E0184 X Dry pressure mattress E0185 X Gel or gel-like pressure pad for mattress, standard mattress length and width E0186 X Air pressure mattress E0187 X Water pressure mattress E0188 X Synthetic sheepskin pad E0189 X Lambswool sheepskin pad, any size E0193 X Powered air flotation bed (low air loss therapy) E0194 X Air fluidized bed E0196 X Gel pressure mattress E0197 X Air pressure pad for mattress, standard mattress length and width E0198 X Water pressure pad for mattress, standard mattress length and width E0199 X Dry pressure pad for mattress, standard mattress length and width E0250 X Hospital bed, fixed height, with any type of side rails, with mattress E0251 X Hospital bed, fixed height, with any type side rails, without mattress E0255 X Hospital bed, variable height, hi-lo, with any type side rails, with mattress E0256 X Hospital bed, variable height, hi-lo, with any type side rails, without mattress E0260 X Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress E0261 X Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress E0265 X Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress E0266 X Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress E0290 X Hospital bed, fixed height, without side rails, with mattress E0291 X Hospital bed, fixed height, without side rails, without mattress Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description E0292 X Hospital bed, variable height, hi-lo, without side rails, with mattress E0293 X Hospital bed, variable height, hi-lo, without side rails, without mattress E0294 X Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress E0295 X Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress E0296 X Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress E0297 X Hospital bed, total electric (head, foot and height adjustments), without side rails, without mattress Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with E0301 X any type side rails, without mattress Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without E0302 X mattress Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds but less than or equal to 600 pounds, with E0303 X any type side rails, with mattress Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with E0304 X mattress Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above E0328 X the spring, includes mattress Hospital bed, pediatric, electric or semi-electric, manual, 360 degree side enclosures, top of headboard, footboard and side E0329 X rails up to 24 inches above the spring, includes mattress E0371 X Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width E0372 X Powered air overlay for mattress, standard mattress length and width E0373 X Nonpowered advanced pressure reducing mattress Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, E0424 X nebulizer, cannula or mask, and tubing Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and E0431 X tubing Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, E0434 X contents gauge, cannula or mask, and tubing Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or E0439 X mask, and tubing E0445 X Oximeter device for measuring blood oxygen levels non-invasively Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal E0470 X or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capability, backup rate feature, used with noninvasive interface, e.g., nasal or facial E0471 X mask (intermittent assist device with continuous positive airway pressure device) High frequency chest wall oscillation air-pulse generator system, (including hoses and vest), each E0483 X Oscillatory Device for Bronchial Drainage (The Vest) Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting E0485 X and adjustment Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes E0486 X fitting and adjustment E0601 X Continuous positive airway pressure (CPAP) device E0618 X Apnea monitor, without recording feature E0619 X Apnea monitor, with recording feature E0625 X Patient lift, bathroom or toilet, not otherwise classifies E0637 X Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels X Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without E0638 wheels E0641 X Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels E0642 X Standing frame/table system, mobile (dynamic stander), any size including pediatric E0650 X Pneumatic Compressor, non-segmental home model E0651 X Pneumatic compressor, segmental home model without calibrated gradient pressure E0652 X Pneumatic Compressor, Segmental Home Model with calibrated gradient pressure Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral E0675 X system) E0676 X Intermittent Limb Compression device (includes all accessories), not otherwise specified E0720 X TENS, two lead, localized stimulation E0730 X TENS, four or more leads, for multiple nerve stimulation Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient’s skin by E0731 X layers of fabric) E0747 X Osteogenesis stimulator, electrical, noninvasive, other than spinal applications Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description E0748 X Osteogenesis stimulator, electrical, noninvasive, spinal applications E0760 X Osteogenesis stimulator, low intensity ultrasound, noninvasive E0762 X Transcutaneous electrical joint stimulation device system, includes all accessories Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer E0764 X control, used for walking by spinal cord injured, entire system, after completion of training program E0784 X External Ambulatory infusion pump, Insulin E0983 X Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick controlled E0984 X Manual wheelchair accessory, power add-onto convert manual wheelchair to motorized wheelchair, tiller control E0986 X Manual wheelchair accessory, push activated power assist, each E1083 X Hemi-wheelchair, fixed full-length arms, swing-away detachable elevating legrest E1084 X Hemi-wheelchair, detachable arms desk or full-length arms, swing-away detachable elevating legrests E1085 X Hemi-wheelchair, fixed full-length arms, swing-away detachable footrests E1086 X Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1087 X High strength lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1088 X High strength lightweight wheelchair, detachable arms desk or full-length, swing-away detachable elevating legrests E1089 X High-strength lightweight wheelchair, fixed-length arms, swing-away detachable footrest E1090 X High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1092 X Wide heavy-duty wheel chair, detachable arms (desk or full-length), swing-away detachable elevating legrests E1093 X Wide heavy-duty wheelchair, detachable arms, desk or full-length arms, swing-away detachable footrests E1100 X Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1110 X Semi-reclining wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1130 X Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests E1140 X Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests E1150 X Wheelchair, detachable arms, desk or full-length swing-away detachable elevating legrests E1160 X Wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1161 X Manual adult size wheelchair, includes tilt in space E1170 X Amputee wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1171 X Amputee wheelchair, fixed full-length arms, without footrests or legrest E1172 X Amputee wheelchair, detachable arms (desk or full-length) without footrests or legrest Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description E1180 X Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable footrests E1190 X Amputee wheelchair, detachable arms (desk or full-length) swing-away detachable elevating legrests E1195 X Heavy-duty wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1200 X Amputee wheelchair, fixed full-length arms, swing-away detachable footrest E1220 X Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification E1221 X Wheelchair with fixed arm, footrests E1222 X Wheelchair with fixed arm, elevating legrests E1223 X Wheelchair with detachable arms, footrests E1224 X Wheelchair with detachable arms, elevating legrests E1229 X Wheelchair, pediatric size, not otherwise specified E1230 X Power operated vehicle (3- or 4-wheel nonhighway), specify brand name and model number E1231 X Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system E1232 X Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system E1233 X Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system E1234 X Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system E1235 X Wheelchair, pediatric size, rigid, adjustable, with seating system E1236 X Wheelchair, pediatric size, folding, adjustable, with seating system E1237 X Wheelchair, pediatric size, rigid, adjustable, without seating system E1238 X Wheelchair, pediatric size, folding, adjustable, without seating system E1239 X Power wheelchair, pediatric size, not otherwise specified E1240 X Lightweight wheelchair, detachable arms, (desk or full-length) swing-away detachable, elevating legrest E1250 X Lightweight wheelchair, fixed full-length arms, swing-away detachable footrest E1260 X Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1270 X Lightweight wheelchair, fixed full-length arms, swing-away detachable elevating legrests E1280 X Heavy-duty wheelchair, detachable arms (desk or full-length) elevating legrests E1285 X Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest E1290 X Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest E1295 X Heavy-duty wheelchair, fixed full-length arms, elevating legrest E1296 X Special wheelchair seat height from floor Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description E1297 X Special wheelchair seat depth, by upholstery E1298 X Special wheelchair seat depth and/or width, by construction E1353 X Oxygen related equipment regulator Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow E1390 X rate, each Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow E1391 X rate, each E1392 X Portable oxygen concentrator, rental E1399 X DME, miscellaneous E1405 X Oxygen and water vapor enriching system with heated delivery E1406 X Oxygen and water vapor enriching system without heated delivery E1699 X Dialysis equipment, not otherwise specified E2402 X Negative pressure wound therapy electrical pump, stationary or portable E2500 X Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time X Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 E2502 minutes recording time X Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 E2504 minutes recording time E2506 X Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time X Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with E2508 the device X Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of E2510 device access E2511 X Speech generating software program, for personal computer or personal digital assistant E2512 X Accessory for speech generating device, mounting system E2599 X Accessory for speech generating device, not otherwise classified E8000 X Gait trainer, pediatric size, posterior support, includes all accessories and components E8001 X Gait trainer, pediatric size, upright support, includes all accessories and components E8002 X Gait trainer, pediatric size, anterior support, includes all accessories and components K0001 X Standard Wheelchair Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description K0002 X Standard hemi (low seat) Wheelchair K0003 X Lightweight wheelchair K0004 X High strength, lightweight wheelchair K0005 X Ultralightweight wheelchair K0006 X Heavy-duty wheelchair K0007 X Extra heavy-duty wheelchair K0008 X Custom manual wheelchair/base K0009 X Other manual wheelchair/base K0010 X Standard-weight frame motorized/power wheelchair X Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor K0011 dampening, acceleration control and braking K0012 X Lightweight portable motorized/power wheelchair K0013 X Custom motorized/power wheelchair base K0014 X Other motorized/power wheelchair base K0108 X Wheelchair component or accessory, not otherwise specified Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, K0738 X regulator, flowmeter, humidifier, cannula or mask, and tubing K0800 X Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds K0801 X Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds K0802 X Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds K0806 X Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds K0807 X Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds K0808 X Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds K0812 X Power operated vehicle, not otherwise classified Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 K0813 X pounds K0814 X Power wheelchair, group 1 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds K0815 X Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds K0816 X Power wheelchair, group 1 standard, captain’s chair, patient weight capacity up to and including 300 pounds Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description K0820 X Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0821 X Power wheelchair, group 2 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds K0822 X Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0823 X Power wheelchair, group 2 standard, captain’s chair, patient weight capacity up to and including 300 pounds K0824 X Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0825 X Power wheelchair, group 2 heavy-duty, captain’s chair, patient weight capacity 301 to 450 pounds K0826 X Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds K0827 X Power wheelchair, group 2 very heavy-duty, captain’s chair, patient weight capacity 451 to 600 pounds K0828 X Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more K0829 X Power wheelchair, group 2 extra heavy-duty, captain’s chair, patient weight 601 pounds or more Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 K0830 X pounds K0831 X Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including K0835 X 300 pounds Power wheelchair, group 2 standard, single power option, captain’s chair, patient weight capacity up to and including 300 K0836 X pounds K0837 X Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0838 X Power wheelchair, group 2 heavy-duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 K0839 X pounds Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or K0840 X more Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including K0841 X 300 pounds Power wheelchair, group 2 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 K0842 X pounds Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0843 X pounds K0848 X Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description K0849 X Power wheelchair, group 3 standard, captain’s chair, patient weight capacity up to and including 300 pounds K0850 X Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0851 X Power wheelchair, group 3 heavy-duty, captain’s chair, patient weight capacity 301 to 450 pounds K0852 X Power wheelchair, group 3 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds K0853 X Power wheelchair, group 3 very heavy-duty, captain’s chair, patient weight capacity 451 to 600 pounds K0854 X Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more K0855 X Power wheelchair, group 3 extra heavy-duty, captain’s chair, patient weight capacity 601 pounds or more Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including K0856 X 300 pounds Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 K0857 X pounds K0858 X Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds K0859 X Power wheelchair, group 3 heavy-duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 K0860 X pounds Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including K0861 X 300 pounds Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0862 X pounds Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 K0863 X pounds Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds K0864 X or more K0868 X Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0869 X Power wheelchair, group 4 standard, captain’s chair, patient weight capacity up to and including 300 pounds K0870 X Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0871 X Power wheelchair, group 4 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including K0877 X 300 pounds K0878 X Power wheelchair, group 4 standard, single power option, captain’s chair, patient weight capacity up to and including 300 Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description pounds K0879 X Power wheelchair, group 4 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds K0880 X Power wheelchair, group 4 very heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including K0884 X 300 pounds Power wheelchair, group 4 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 K0885 X pounds Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 K0886 X pounds Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including K0890 X 125 pounds Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including K0891 X 125 pounds K0898 X Power wheelchair, not otherwise classified K0899 X Power mobility device, not coded by DME PDAC or does not meet criteria K0900 X Customized durable medical equipment, other than wheelchair (start date 7/1/13) Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), K0901 X medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), K0902 X medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk L0456 X motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygealjunction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, L0457 X produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the- shelf Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior L0458 X extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the L0460 X symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the L0462 X symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 4 rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to L0464 X the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross L0467 X trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the- shelf Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, L0468 X and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts L0469 X gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame and flexible soft anterior apron with straps, L0470 X closures and padding extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with 2 anterior components (one pubic and one sternal), posterior and lateral pads with straps L0472 X and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior L0480 X extends from symphysis pubis to sterk0nal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from L0482 X symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior L0484 X extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from L0486 X symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from L0488 X symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 2 rigid plastic shells, L0491 X posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal L0631 X junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by L0635 X rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid L0636 X lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure L0637 X to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure L0638 X to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the L0639 X intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the L0640 X intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated L0641 X Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, L0642 X produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 L0643 X vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal L0648 X junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary L0650 X pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the L0651 X intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf L0700 X Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral control, molded to patient model, (Minerva type) Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral-control, molded to patient model, with interface L0710 X material, (Minerva type) Knee orthotic, adjustable knee joints (unicentric or polycentric), positional orthotic, rigid support, prefabricated, includes L1832 X fitting and adjustment L1833 X Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf L1834 X Knee orthotic (KO), without knee joint, rigid, custom fabricated L1840 X Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated Knee orthosis, single upright, thight and calf, with adjustable flexion and extension (unicentric or polycentric), medial-lateral L1843 X and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), L1844 X medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial- L1845 X lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial- L1846 X lateral and rotation control, with or without varus/valgus adjustment, custom fabricated L1848 X Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf L1860 X Knee orthotic (KO), modification of supracondylar prosthetic socket, custom fabricated (SK) L1930 X Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes fitting and adjustment Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and L1932 X adjustment L1940 X Ankle-foot orthotic (AFO), plastic or other material, custom fabricated L1945 X Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated L1960 X Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated L1971 X Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, includes fitting and adjustment L3230 X Orthopedic footwear, custom shoe, depth inlay, each L3330 X Lift, elevation, metal extension (skate) L3678 X Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include L3806 X soft interface material, straps, custom fabricated, includes fitting and adjustment Wrist-hand-finger orthotic (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, L3808 X includes fitting and adjustment Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist L3900 X or finger driven, custom fabricated Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable L3901 X driven, custom fabricated L3904 X Wrist-hand-finger orthotic (WHFO), external powered, electric, custom fabricated Wrist-hand orthotic (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, L3905 X straps, custom fabricated, includes fitting and adjustment L3906 X Wrist-hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description adjustment Wrist hand orthosis, includes one or more nontorsion joints(s), elastic bands, turnbuckles, may include soft interface, straps, L3916 X prefabricated, off-the-shelf Hand finger orthotic (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, L3921 X straps, custom fabricated, includes fitting and adjustment Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch L4631 X support, plastic or other material, includes straps and closures, custom fabricated L5000 X Partial foot, shoe insert with longitudinal arch, toe filler L5010 X Partial foot, molded socket, ankle height, with toe filler L5020 X Partial foot, molded socket, tibial tubercle height, with toe filler L5050 X Ankle, Symes, molded socket, SACH foot L5060 X Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot L5100 X Below knee, molded socket, shin, SACH foot L5105 X Below knee, plastic socket, joints and thigh lacer, SACH foot L5150 X Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot L5160 X Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot L5200 X Above knee, molded socket, single axis constant friction knee, shin, SACH foot L5210 X Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each L5220 X Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each L5230 X Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot L5250 X Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot L5270 X Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot L5280 X Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot L5301 X Below knee, molded socket, shin, SACH foot, endoskeletal system L5312 X Knee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal system L5321 X Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee L5331 X Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot L5341 X Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot L5400 X Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description cast change, below knee Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below L5410 X knee, each additional cast change and realignment Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and L5420 X one cast change AK or knee disarticulation Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, AK or L5430 X knee disarticulation, each additional cast change and realignment L5450 X Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee L5460 X Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee L5500 X Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed Initial, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, L5505 X direct formed L5510 X Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct L5520 X formed Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded L5530 X to model Preparatory, below knee PTB type socket, nonalignable system, no cover, SACH foot, prefabricated, adjustable open end L5535 X socket Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to L5540 X model Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster L5560 X socket, molded to model Preparatory, above knee – knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, L5570 X thermoplastic or equal, direct formed Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, L5580 X thermoplastic or equal, molded to model Preparatory, above knee – knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, L5585 X prefabricated adjustable open end socket L5590 X Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description laminated socket, molded to model L5595 X Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model L5600 X Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model L5610 X Addition to lower extremity, endoskeletal system, above knee, hydracadence system Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with friction swing phase L5611 X control Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with hydraulic swing phase L5613 X control Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase L5614 X control L5616 X Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control L5617 X Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each L5618 X Addition to lower extremity, test socket, Symes L5620 X Addition to lower extremity, test socket, below knee L5622 X Addition to lower extremity, test socket, knee disarticulation L5624 X Addition to lower extremity, test socket, above knee L5626 X Addition to lower extremity, test socket, hip disarticulation L5628 X Addition to lower extremity, test socket, hemipelvectomy L5629 X Addition to lower extremity, below knee, acrylic socket L5630 X Addition to lower extremity, Symes type, expandable wall socket L5631 X Addition to lower extremity, above knee or knee disarticulation, acrylic socket L5632 X Addition to lower extremity, Symes type, PTB brim design socket L5634 X Addition to lower extremity, Symes type, posterior opening (Canadian) socket L5636 X Addition to lower extremity, Symes type, medial opening socket L5637 X Addition to lower extremity, below knee, total contact L5368 X Addition to lower extremity, below knee, leather socket L5639 X Addition to lower extremity, below knee, wood socket L5640 X Addition to lower extremity, knee disarticulation, leather socket L5642 X Addition to lower extremity, above knee, leather socket Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L5643 X Addition to lower extremity, hip disarticulation, flexible inner socket, external frame L5644 X Addition to lower extremity, above knee, wood socket L5645 X Addition to lower extremity, below knee, flexible inner socket, external frame L5646 X Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket L5647 X Addition to lower extremity, below knee, suction socket L5648 X Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket L5649 X Addition to lower extremity, ischial containment/narrow M-L socket L5650 X Additions to lower extremity, total contact, above knee or knee disarticulation socket L5651 X Addition to lower extremity, above knee, flexible inner socket, external frame L5652 X Addition to lower extremity, suction suspension, above knee or knee disarticulation socket L5653 X Addition to lower extremity, knee disarticulation, expandable wall socket L5654 X Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal) L5655 X Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal) L5656 X Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal) L5658 X Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal) L5661 X Addition to lower extremity, socket insert, multidurometer Symes L5665 X Addition to lower extremity, socket insert, multidurometer, below knee L5666 X Addition to lower extremity, below knee, cuff suspension L5668 X Addition to lower extremity, below knee, molded distal cushion L5670 X Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar) Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard, or equal), excludes L5671 X socket insert L5672 X Addition to lower extremity, below knee, removable medial brim suspension Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, L5673 X silicone gel, elastomeric or equal, for use with locking mechanism L5676 X Additions to lower extremity, below knee, knee joints, single axis, pair L5677 X Additions to lower extremity, below knee, knee joints, polycentric, pair L5678 X Additions to lower extremity, below knee, joint covers, pair L5679 X Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description silicone gel, elastomeric or equal, not for use with locking mechanism L5680 X Addition to lower extremity, below knee, thigh lacer, nonmolded Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic L5681 X amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only L5682 X Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical L5683 X traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only L5684 X Addition to lower extremity, below knee, fork strap L5685 X Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each L5686 X Addition to lower extremity, below knee, back check (extension control) L5688 X Addition to lower extremity, below knee, waist belt, webbing L5690 X Addition to lower extremity, below knee, waist belt, padded and lined L5692 X Addition to lower extremity, above knee, pelvic control belt, light L5694 X Addition to lower extremity, above knee, pelvic control belt, padded and lined L5695 X Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each L5696 X Addition to lower extremity, above knee or knee disarticulation, pelvic joint L5697 X Addition to lower extremity, above knee or knee disarticulation, pelvic band L5698 X Addition to lower extremity, above knee or knee disarticulation, Silesian bandage L5699 X All lower extremity prostheses, shoulder harness L5700 X Replacement, socket, below knee, molded to patient model L5701 X Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model L5702 X Replacement, socket, hip disarticulation, including hip joint, molded to patient model L5703 X Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only L5704 X Custom shaped protective cover, below knee L5705 X Custom shaped protective cover, above knee L5706 X Custom shaped protective cover, knee disarticulation L5707 X Custom shaped protective cover, hip disarticulation L5710 X Addition, exoskeletal knee-shin system, single axis, manual lock L5711 X Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L5712 X Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) L5714 X Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control L5716 X Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock L5718 X Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control L5722 X Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control L5724 X Addition, exoskeletal knee-shin system, single axis, fluid swing phase control L5726 X Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control L5728 X Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control L5780 X Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control L5781 X Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy- L5782 X duty L5785 X Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) L5790 X Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) L5795 X Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) L5810 X Addition, endoskeletal knee-shin system, single axis, manual lock L5811 X Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material L5812 X Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) L5814 X Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock L5816 X Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock L5818 X Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control L5822 X Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control L5824 X Addition, endoskeletal knee-shin system, single axis, fluid swing phase control L5826 X Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame L5828 X Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control L5830 X Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control L5840 X Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control L5845 X Addition, endoskeletal knee-shin system, stance flexion feature, adjustable L5848 X Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L5850 X Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist L5855 X Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance L5856 X phase, includes electronic sensor(s), any type Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, L5857 X includes electronic sensor(s), any type Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, L5858 X includes electronic sensor(s), any type Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist L5859 X control, includes any type motor(s) L5910 X Addition, endoskeletal system, below knee, alignable system L5920 X Addition, endoskeletal system, above knee or hip disarticulation, alignable system L5925 X Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock L5930 X Addition, endoskeletal system, high activity knee control frame L5940 X Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) L5950 X Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) L5960 X Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion L5961 X and/or extension control L5962 X Addition, endoskeletal system, below knee, flexible protective outer surface covering system L5964 X Addition, endoskeletal system, above knee, flexible protective outer surface covering system L5966 X Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system L5968 X Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature L5969 X Addition, endoskeletal ankle-foot or ankle-system, power assist, includes any type motor(s) L5970 X All lower extremity prostheses, foot, external keel, SACH foot L5971 X All lower extremity prostheses, solid ankle cushion heel (SACH) foot, replacement only L5972 X All lower extremity prostheses, foot, flexible keel Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power L5973 X source L5974 X All lower extremity prostheses, foot, single axis ankle/foot Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L5975 X All lower extremity prostheses, combination single axis ankle and flexible keel foot L5976 X All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal) L5978 X All lower extremity prostheses, foot, multiaxial ankle/foot L5979 X All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system L5980 X All lower extremity prostheses, flex-foot system L5981 X All lower extremity prostheses, flex-walk system or equal L5982 X All exoskeletal lower extremity prostheses, axial rotation unit L5984 X All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability L5985 X All endoskeletal lower extremity prostheses, dynamic prosthetic pylon L5986 X All lower extremity prostheses, multiaxial rotation unit (MCP or equal) L5987 X All lower extremity prostheses, shank foot system with vertical loading pylon L5988 X Addition to lower limb prosthesis, vertical shock reducing pylon feature L5990 X Addition to lower extremity prosthesis, user adjustable heel height L5999 X Lower extremity prosthesis, not otherwise specified L6000 X Partial hand, thumb remaining L6010 X Partial hand, little and/or ring finger remaining L6020 X Partial hand, no finger remaining Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable L6025 X forearm section, electrodes and cables, 2 batteries, charger, myoelectric control of terminal device L6050 X Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad L6055 X Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad L6100 X Below elbow, molded socket, flexible elbow hinge, triceps pad L6110 X Below elbow, molded socket (Muenster or Northwestern suspension types) L6120 X Below elbow, molded double wall split socket, step-up hinges, half cuff L6130 X Below elbow, molded double wall split socket, stump activated locking hinge, half cuff L6200 X Elbow disarticulation, molded socket, outside locking hinge, forearm L6205 X Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm L6250 X Above elbow, molded double wall socket, internal locking elbow, forearm L6300 X Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L6310 X Shoulder disarticulation, passive restoration (complete prosthesis) L6320 X Shoulder disarticulation, passive restoration (shoulder cap only) L6350 X Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm L6360 X Interscapular thoracic, passive restoration (complete prosthesis) L6370 X Interscapular thoracic, passive restoration (shoulder cap only) Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of L6380 X components, and one cast change, wrist disarticulation or below elbow Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of L6382 X components, and one cast change, elbow disarticulation or above elbow Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of L6384 X components, and one cast change, shoulder disarticulation or interscapular thoracic L6386 X Immediate postsurgical or early fitting, each additional cast change and realignment L6388 X Immediate postsurgical or early fitting, application of rigid dressing only L6400 X Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6450 X Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6500 X Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6550 X Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6570 X Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of L6580 X eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight L6582 X harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight L6584 X harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, L6586 X fair lead cable control, USMC or equal pylon, no cover, direct formed Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction L6588 X wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, L6590 X chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L6600 X Upper extremity additions, polycentric hinge, pair L6605 X Upper extremity additions, single pivot hinge, pair L6610 X Upper extremity additions, flexible metal hinge, pair L6611 X Addition to upper extremity prosthesis, external powered, additional switch, any type L6615 X Upper extremity addition, disconnect locking wrist unit L6616 X Upper extremity addition, additional disconnect insert for locking wrist unit, each L6620 X Upper extremity addition, flexion/extension wrist unit, with or without friction Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal L6621 X device L6623 X Upper extremity addition, spring assisted rotational wrist unit with latch release L6624 X Upper extremity addition, flexion/extension and rotation wrist unit L6625 X Upper extremity addition, rotation wrist unit with cable lock L6628 X Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal L6629 X Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal L6630 X Upper extremity addition, stainless steel, any wrist L6632 X Upper extremity addition, latex suspension sleeve, each L6635 X Upper extremity addition, lift assist for elbow L6637 X Upper extremity addition, nudge control elbow lock L6638 X Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow L6640 X Upper extremity additions, shoulder abduction joint, pair L6641 X Upper extremity addition, excursion amplifier, pulley type L6642 X Upper extremity addition, excursion amplifier, lever type L6645 X Upper extremity addition, shoulder flexion-abduction joint, each Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with L6646 X body powered or external powered system L6647 X Upper extremity addition, shoulder lock mechanism, body powered actuator L6648 X Upper extremity addition, shoulder lock mechanism, external powered actuator L6650 X Upper extremity addition, shoulder universal joint, each L6655 X Upper extremity addition, standard control cable, extra Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L6660 X Upper extremity addition, heavy-duty control cable L6665 X Upper extremity addition, Teflon, or equal, cable lining L6670 X Upper extremity addition, hook to hand, cable adapter L6672 X Upper extremity addition, harness, chest or shoulder, saddle type L6675 X Upper extremity addition, harness, (e.g., figure of eight type), single cable design L6676 X Upper extremity addition, harness, (e.g., figure of eight type), dual cable design L6677 X Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow L6680 X Upper extremity addition, test socket, wrist disarticulation or below elbow L6682 X Upper extremity addition, test socket, elbow disarticulation or above elbow L6684 X Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic L6686 X Upper extremity addition, suction socket L6687 X Upper extremity addition, frame type socket, below elbow or wrist disarticulation L6688 X Upper extremity addition, frame type socket, above elbow or elbow disarticulation L6689 X Upper extremity addition, frame type socket, shoulder disarticulation L6690 X Upper extremity addition, frame type socket, interscapular-thoracic L6691 X Upper extremity addition, removable insert, each L6692 X Upper extremity addition, silicone gel insert or equal, each L6693 X Upper extremity addition, locking elbow, forearm counterbalance Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, L6694 X socket insert, silicone gel, elastomeric or equal, for use with locking mechanism Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, L6695 X socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical L6696 X traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or L6697 X atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only L6698 X Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert L6703 X Terminal device, passive hand/mitt, any material, any size L6704 X Terminal device, sport/recreational/work attachment, any material, any size Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L6706 X Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined L6707 X Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined L6708 X Terminal device, hand, mechanical, voluntary opening, any material, any size L6709 X Terminal device, hand, mechanical, voluntary closing, any material, any size L6711 X Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric L6712 X Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric L6713 X Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric L6714 X Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric L6715 X Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement L6721 X Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined L6722 X Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined L6805 X Addition to terminal device, modifier wrist unit L6810 X Addition to terminal device, precision pinch device Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp L6880 X patterns, includes motor(s) L6881 X Automatic grasp feature, addition to upper limb electric prosthetic terminal device L6882 X Microprocessor control feature, addition to upper limb prosthetic terminal device L6883 X Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power L6884 X Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external L6885 X power L6890 X Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment L6895 X Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated L6900 X Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining L6905 X Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining L6910 X Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining L6915 X Hand restoration (shading and measurements included), replacement glove for above Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, L6920 X 2 batteries and 1 charger, switch control of terminal device Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, L6925 X cables, 2 batteries and one charger, myoelectronic control of terminal device Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 L6930 X batteries and one charger, switch control of terminal device Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 L6935 X batteries and one charger, myoelectronic control of terminal device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto L6940 X Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto L6945 X Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or L6950 X equal switch, cables, 2 batteries and one charger, switch control of terminal device Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or L6955 X equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, L6960 X mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, L6965 X mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, L6970 X mechanical elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, L6975 X mechanical elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device L7007 X Electric hand, switch or myoelectric controlled, adult L7008 X Electric hand, switch or myoelectric, controlled, pediatric L7009 X Electric hook, switch or myoelectric controlled, adult L7040 X Prehensile actuator, switch controlled L7045 X Electric hook, switch or myoelectric controlled, pediatric L7170 X Electronic elbow, Hosmer or equal, switch controlled Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L7180 X Electronic elbow, microprocessor sequential control of elbow and terminal device L7181 X Electronic elbow, microprocessor simultaneous control of elbow and terminal device L7185 X Electronic elbow, adolescent, Variety Village or equal, switch controlled L7186 X Electronic elbow, child, Variety Village or equal, switch controlled L7190 X Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled L7191 X Electronic elbow, child, Variety Village or equal, myoelectronically controlled L7260 X Electronic wrist rotator, Otto Bock or equal L7261 X Electronic wrist rotator, for Utah arm L7360 X Six volt battery, each L7362 X Battery charger, 6 volt, each L7364 X Twelve volt battery, each L7366 X Battery charger, twelve volt, each L7367 X Lithium ion battery, replacement L7368 X Lithium ion battery charger, replacement only L7400 X Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) L7401 X Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon L7402 X fiber or equal) L7403 X Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material L7404 X Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material L7405 X Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material L7499 X Upper extremity prosthesis, not otherwise specified L7510 X Repair of prosthetic device, repair or replace minor parts L7520 X Repair prosthetic device, labor component, per 15 minutes L7600 X Prosthetic donning sleeve, any material, each L8400 X Prosthetic sheath, below knee, each L8410 X Prosthetic sheath, above knee, each L8415 X Prosthetic sheath, upper limb, each L8417 X Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L8420 X Prosthetic sock, multiple ply, below knee, each L8430 X Prosthetic sock, multiple ply, above knee, each L8440 X Prosthetic shrinker, below knee, each L8460 X Prosthetic shrinker, above knee, each L8470 X Prosthetic sock, single ply, fitting, below knee, each L8480 X Prosthetic sock, single ply, fitting, above knee, each L8465 X Prosthetic sock, single ply, fitting, upper limb, each L8499 X Unlisted procedure for misc. prosthetic services L8614 X Cochlear device, includes all internal and external components L8615 X Headset/headpiece for use with cochlear implant device, replacement L8616 X Microphone for use with cochlear implant device, replacement L8617 X Transmitting coil for use with cochlear implant device, replacement L8618 X Transmitter cable for use with cochlear implant device, replacement L8619 X Cochlear implant, external speech processor and controller, integrated system, replacement L8621 X Zinc air battery for use with cochlear implant device, replacement, each L8622 X Alkaline battery for use with cochlear implant device, any size, replacement, each L8623 X Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each L8624 X Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each L8627 X Cochlear implant, external speech processor, component, replacement L8628 X Cochlear implant, external controller component, replacement L8679 X Implantable neurostimulator, pulse generator, any type L8680 X Implantable neurostimulator electrode, each L8685 X Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8686 X Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension L8687 X Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8688 X Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension L8690 X Auditory osseointegrated device, includes all internal and external components Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or L8692 X other means of external attachment Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description L8693 X Auditory osseointegrated device abutment, any length, replacement only L8695 X External recharging system for battery (external) for use with implantable neurostimulator, replacement only L9900 X Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code V2500 X Contact lens, PMMA, spherical, per lens V2501 X Contact lens, PMMA, toric or prism ballast, per lens V2503 X Contact lens, PMMA, color vision deficiency, per lens V2510 X Contact lens, gas permeable, spherical, per lens V2511 X Contact lens, gas permeable, toric, prism ballast, per lens V2513 X Contact lens, gas permeable, extended wear, per lens V2520 X Contact lens, hydrophilic, spherical, per lens V2521 X Contact lens, hydrophilic, toric, or prism ballast, per lens V2523 X Contact lens, hydrophilic, extended wear, per lens V2530 X Contact lens, scleral, gas impermeable, per lens V2531 X Contact lens, scleral, gas permeable, per lens V2599 X Contact lens, other type V2600 X Hand held low vision aids and other nonspectacle mounted aids V2610 X Single lens spectacle mounted low vision aids X Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound V2615 microscopic lens system V2784 X Lens, polycarbonate or equal, any index, per lens (for adults, age 21 or older) V2623 X Prosthetic eye, plastic, custom V2624 X Polishing/resurfacing of ocular prosthesis V2625 X Enlargement of ocular prosthesis V2626 X Reduction of ocular prosthesis V2627 X Scleral cover shell V2628 X Fabrication and fitting of ocular conformer V2629 X Prosthetic eye, other type V5030 X Hearing aid, monaural, body worn, air conduction (effective 1/1/15) V5040 X Hearing aid, monaural, body worn, bone conduction (effective 1/1/15) Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description V5050 X Hearing aid, monaural, in the ear (effective 1/1/15) V5060 X Hearing aid, monaural, behind the ear (effective 1/1/15) V5070 X Glasses, air conduction (effective 1/1/15) V5080 X Glasses, bone conduction (effective 1/1/15) V5090 X Dispensing fee, unspecified hearing aid (effective 1/1/15) V5095 X Semi-implantable middle ear hearing prosthesis (effective 1/1/15) V5100 X Hearing aid, bilateral body worn (effective 1/1/15) V5110 X Dispensing fee, bilateral (effective 1/1/15) V5120 X Hearing aid, binaural, body (effective 1/1/15) V5130 X Hearing aid, binaural, in the ear (effective 1/1/15) V5140 X Hearing aid, binaural, behind the ear (effective 1/1/15) V5150 X Hearing aid, binaural, glasses (effective 1/1/15) V5160 X Dispensing fee, binaural (effective 1/1/15) V5170 X Hearing aid, CROS, in the ear (effective 1/1/15) V5180 X Hearing aid, CROS, behind the ear (effective 1/1/15) V5190 X Hearing aid, CROS, glasses (effective 1/1/15) V5200 X Dispensing fee, CROS (effective 1/1/15) V5210 X Hearing aid, BICROS, in the ear (effective 1/1/15) V5220 X Hearing aid, BICROS, behind the ear (effective 1/1/15) V5230 X Hearing aid, BICROS, glasses (effective 1/1/15) V5240 X Dispensing fee, BICROS (effective 1/1/15) V5241 X Dispensing fee, monaural hearing aid, any type (effective 1/1/15) V5242 X Hearing aid, analog, monaural, CIC (completely in the ear canal) (effective 1/1/15) V5243 X Hearing aid, analog, monaural, ITC (in the canal) (effective 1/1/15) V5244 X Hearing aid, digitally programmable analog, monaural, CIC (effective 1/1/15) V5245 X Hearing aid, digitally programmable, analog, monaural, ITC (effective 1/1/15) V5246 X Hearing aid, digitally programmable, analog, monaural, ITE (in the ear) (effective 1/1/15) V5247 X Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) V5248 X Hearing aid, analog, binaural, CIC Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description V5249 X Hearing aid, analog, binaural, ITC (effective 1/1/15) V5250 X Hearing aid, digitally programmable analog, binaural, CIC (effective 1/1/15) V5251 X Hearing aid, digitally programmable analog, binaural, ITC (effective 1/1/15) V5252 X Hearing aid, digitally programmable, binaural, ITE (effective 1/1/15) V5253 X Hearing aid, digitally programmable, binaural, BTE (effective 1/1/15) V5254 X Hearing aid, digital, monaural, CIC (effective 1/1/15) V5255 X Hearing aid, digital, monaural, ITC (effective 1/1/15) V5256 X Hearing aid, digital, monaural, ITE (effective 1/1/15) V5257 X Hearing aid, digital, monaural, BTE (effective 1/1/15) V5258 X Hearing aid, digital, binaural, CIC (effective 1/1/15) V5259 X Hearing aid, digital, binaural, ITC (effective 1/1/15) V5260 X Hearing aid, digital, binaural, ITE (effective 1/1/15) V5261 X Hearing aid, digital, binaural, BTE (effective 1/1/15) V5262 X Hearing aid, disposable, any type, monaural (effective 1/1/15) V5263 X Hearing aid, disposable, any type, binaural (effective 1/1/15) V5264 X Ear mold/insert, not disposable, any type (effective 1/1/15) V5265 X Ear mold/insert, disposable, any type (effective 1/1/15) V5266 X Battery for use in hearing device (effective 1/1/15) V5267 X Hearing aid or assistive listening device/supplies/accessories, not otherwise specified (effective 1/1/15) V5268 X Assistive listening device, telephone amplifier, any type V5269 X Assistive listening device, alerting, any type V5270 X Assistive listening device, television amplifier, any type V5271 X Assistive listening device, television amplifier, any type (effective 1/1/15) V5272 X Assistive listening device, TDD V5273 X Assistive listening device, for use with cochlear implant V5274 X Assistive listening device, not otherwise specified V5275 X Ear impression, each (effective 1/1/15) X Assistive listening device, personal FM/DM system, monaural (1 receiver, transmitter, microphone), any type (effective V5281 1/1/15) Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS codes that require precertification.

HCPCS QUEST Description V5282 X Assistive listening device, personal FM/DM system, binaural (2 receivers, transmitter, microphone), any type (effective 1/1/15) V5283 X Assistive listening device, personal FM/DM neck, loo induction receiver (effective 1/1/15) V5284 X Assistive listening device, personal FM/DM, ear level receiver (effective 1/1/15) V5285 X Assistive listening device, personal FM/DM, direct audio input receiver (effective 1/1/15) V5286 X Assistive listening device, personal blue tooth FM/DM receiver (effective 1/1/15) V5287 X Assistive listening device, personal FM/DM receiver, not otherwise specified (effective 1/1/15) V5288 X Assistive listening device, personal FM/DM transmitter assistive listening device (effective 1/1/15) V5289 X Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any type (effective 1/1/15) V5290 X Assistive listening device, transmitter microphone, any type (effective 1/1/15) V5298 X Hearing aid, not otherwise classified V5299 X Hearing service, miscellaneous (effective 1/1/15) V5336 X Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) (effective 1/1/15) $500 $500 allowance rule for rental/purchase. Purchase of DME, orthotics, prosthetics or supplies when the allowance is more than allowance X $500 or for rental of such when the total allowance over the rental period will be more than $500. rule Replacement Orthotic/Prosthesis Claims. Employ Edit 408 PB logic (see attachment) which includes 5 year RULE. X Configuration should be consistent with current DME Medical Policy in Section IV. Administrative Guidelines C, D, & E. Employ Same and Similar logic per Medicare (see attachment) which is 5 year RULE. If item replaced before 5 years RULE, X precertify or pend for MM review.