******************************************************************************* ORTHOTIC DEVICES ******************************************************************************* ------------------------------------------------------------------------------- + SPINAL-CERVICAL ------------------------------------------------------------------------------- A8000 PAC: 170 MAX FEE: $ 85.00 EFF DATE: 01/01/07 FULL DESC:HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 A8001 PAC: 170 MAX FEE: $ 130.00 EFF DATE: 01/01/07 FULL DESC:HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 A8002 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/07 FULL DESC:HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 A8003 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/07 FULL DESC:HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 146 A8004 PAC: 170 MAX FEE: $ 75.00 EFF DATE: 01/01/07 FULL DESC:SOFT INTERFACE FOR HELMET, REPLACEMENT ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0112 PAC: 170 MAX FEE: $ 2042.00 EFF DATE: 01/01/04 FULL DESC:CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATED POS: 11 12 99 PROV TYPES: VALID 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: Y COPAY: $ 3.00 L0120 PAC: 170 MAX FEE: $ 15.76 EFF DATE: 10/01/03 FULL DESC:CERVICAL, FLEXIBLE; NON-ADJUSTABLE (FOAM COLLAR) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 L0130 PAC: 170 MAX FEE: $ 294.40 EFF DATE: 07/01/02 FULL DESC:CERVICAL, FLEXIBLE; THERMOPLASTIC COLLAR, MOLDED TO PATIENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0140 PAC: 170 MAX FEE: $ 33.40 EFF DATE: 10/01/03 FULL DESC:CERVICAL, SEMI-RIGID; ADJUSTABLE (PLASTIC COLLAR) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 L0150 PAC: 170 MAX FEE: $ 61.92 EFF DATE: 07/01/02 FULL DESC:CERVICAL, SEMI-RIGID; ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITH MANDIBULAR/OCCIPITAL PIECE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 147 L0160 PAC: 170 MAX FEE: $ 113.79 EFF DATE: 07/01/02 FULL DESC:CERVICAL, SEMI-RIGID; WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0170 PAC: 170 MAX FEE: $ 548.10 EFF DATE: 07/01/02 FULL DESC:CERVICAL COLLAR; MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0172 PAC: 170 MAX FEE: $ 75.89 EFF DATE: 07/01/02 FULL DESC:CERVICAL COLLAR; SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0174 PAC: 170 MAX FEE: $ 449.36 EFF DATE: 07/01/02 FULL DESC:CERVICAL COLLAR; SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION, MULTIPLE POST COLLAR POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0180 PAC: 170 MAX FEE: $ 378.52 EFF DATE: 07/01/02 FULL DESC:CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS; ADJUSTABLE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0190 PAC: 170 MAX FEE: $ 249.64 EFF DATE: 07/01/02 FULL DESC:CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS; ADJUSTABLE CERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 148 L0200 PAC: 170 MAX FEE: $ 233.86 EFF DATE: 07/01/02 FULL DESC:CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS; ADJUSTABLE CERVICAL BARS, AND THORACIC EXTENSION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 S1040 PAC: 170 MAX FEE: $ 2308.00 EFF DATE: 12/01/03 FULL DESC:CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S) POS: 11 99 PROV TYPES: VALID 58 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + SPINAL-THORACIC ------------------------------------------------------------------------------- L0210 PAC: 170 MAX FEE: $ 10.70 EFF DATE: 10/01/03 FULL DESC:THORACIC, RIB BELT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 L0220 PAC: 170 MAX FEE: $ 109.62 EFF DATE: 07/01/02 FULL DESC:THORACIC, RIB BELT; CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL ------------------------------------------------------------------------------- L0450 PAC: 170 MAX FEE: $ 130.83 EFF DATE: 10/01/03 FULL DESC:TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTEVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 149 L0452 PAC: 170 MAX FEE: $ 254.62 EFF DATE: 10/01/03 FULL DESC:TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTEVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0454 PAC: 170 MAX FEE: $ 344.54 EFF DATE: 10/01/03 FULL DESC:TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE, 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 POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0456 PAC: 170 MAX FEE: $ 344.54 EFF DATE: 10/01/03 FULL DESC: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 MOTION IN THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0458 PAC: 170 MAX FEE: $ 590.50 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, 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, CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 150 L0460 PAC: 170 MAX FEE: $ 590.50 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0462 PAC: 170 MAX FEE: $ 590.50 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0464 PAC: 170 MAX FEE: $ 590.50 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0466 PAC: 170 MAX FEE: $ 305.44 EFF DATE: 10/01/03 FULL DESC:TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS, INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 151 L0468 PAC: 170 MAX FEE: $ 382.79 EFF DATE: 10/01/03 FULL DESC:TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME & FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES & PADDING, EXTENDS FROM SACROCOCCYGEAL JUNCTION OVER SCAPULAE, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, & LATERAL FRAME PIECES, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, & CORONAL PLANES, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0470 PAC: 170 MAX FEE: $ 529.68 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO SCAPULA, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, AND LATERAL FRAME PIECES, ROTATIONAL STRENGTH PROVIDED BY SUBCLAVICULAR EXTENSIONS , RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0472 PAC: 170 MAX FEE: $ 325.93 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR & LATERAL FRAME EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH WITH TWO ANTERIOR COMPONENTS (ONE PUBIC & ONE STERNAL), POSTERIOR & LATERAL PADS WITH STRAPS & CLOSURES, LIMITS SPINAL FLEXION, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, & TRANSVERSE PLANES, INCL. FITTING & SHAPING THE FRAME, PREFAB POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0474 PAC: 170 MAX FEE: $ 538.19 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME W/ FLEXIBLE SOFT APRON ANTERIOR W/ MULTIPLE STRAPS, CLOSURES & PADDING, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO SCAPULA, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, & LATERAL FRAME PIECES, ROTATIONAL STRENGTH PROVIDED BY SUBCLAVICULAR EXTENSIONS, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 152 L0480 PAC: 170 MAX FEE: $ 1215.99 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL W/OUT INTERFACE LINER, W/ MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, & TRANSVERSE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0482 PAC: 170 MAX FEE: $ 1358.27 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL W/ INTERFACE LINER, MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, & TRANSVERSE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0484 PAC: 170 MAX FEE: $ 1466.90 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL W/OUT INTERFACE LINER, W/ MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTICS, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0486 PAC: 170 MAX FEE: $ 1647.36 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL W/ INTERFACE LINER, MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDSFROM SYMPHYSIS PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTICS, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 153 L0488 PAC: 170 MAX FEE: $ 1227.37 EFF DATE: 10/01/03 FULL DESC:TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL W/ INTERFACE LINER, MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, & TRANSVERSE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0490 PAC: 170 MAX FEE: $ 1039.20 EFF DATE: 10/01/03 FULL DESC:TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, W/ OVERLAPPING REINFORCED ANTERIOR, W/ MULTIPLE STRAPS & CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION & TERMINATES AT OR BEFORE THE T-9 VERTEBRA, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO XIPHOID, ANTERIOR OPENING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL & CORONAL PLANES, PREFABRICATED, POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0491 PAC: 170 MAX FEE: $ 467.52 EFF DATE: 01/01/06 FULL DESC:TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, 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 TRUCK MOTION IN THE SAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0492 PAC: 170 MAX FEE: $ 467.52 EFF DATE: 01/01/06 FULL DESC:TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC SHELLS, 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 PROVIDED BY OVERLAPPING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 154 L0626 PAC: 170 MAX FEE: $ 62.75 EFF DATE: 01/01/06 FULL DESC:LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0627 PAC: 170 MAX FEE: $ 112.75 EFF DATE: 01/01/06 FULL DESC:LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 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 POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + SPINAL-LUMBAR SACRAL - FLEXIBLE ------------------------------------------------------------------------------- L0628 PAC: 170 MAX FEE: $ 67.53 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE STAYS, SHOULDER STRAPS, PENDOULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0629 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE STAYS, SHOULDER STRAPS, PENDOULOUS ABDOMEN DESIGN, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 155 L0630 PAC: 170 MAX FEE: $ 130.40 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0631 PAC: 170 MAX FEE: $ 826.44 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL 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 POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0632 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL 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, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0633 PAC: 170 MAX FEE: $ 230.86 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAN ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, PREFABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 156 L0634 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0635 PAC: 170 MAX FEE: $ 804.45 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, 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 RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDE STRAPS, PREFABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0636 PAC: 170 MAX FEE: $ 1091.47 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FEXION, 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 RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0637 PAC: 170 MAX FEE: $ 840.44 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, 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 TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDE STRAPS, CLOSURES, MAY INCLUDE PADDING, PREFABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 157 L0638 PAC: 170 MAX FEE: $ 1061.81 EFF DATE: 01/01/06 FULL DESC:LUMBAR-SACRAL ORTHOSIS, 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 TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDE STRAPS, CLOSURES, MAY INCLUDE PADDING, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0639 PAC: 170 MAX FEE: $ 277.90 EFF DATE: 01/01/06 FULL DESC: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 XPHOID, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BY OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, PREFABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0640 PAC: 170 MAX FEE: $ 842.41 EFF DATE: 01/01/06 FULL DESC: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 XPHOID, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BY OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + LUMBAR FLEXION ------------------------------------------------------------------------------- L0625 PAC: 170 MAX FEE: $ 44.34 EFF DATE: 01/01/06 FULL DESC:LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, SHOULDER STRAPS, STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 158 ------------------------------------------------------------------------------- + SPINAL-SACRIOLIAC - FLEXIBLE ------------------------------------------------------------------------------- L0621 PAC: 170 MAX FEE: $ 64.93 EFF DATE: 01/01/06 FULL DESC:SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0622 PAC: 170 MAX FEE: $ 172.27 EFF DATE: 01/01/06 FULL DESC:SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0623 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/06 FULL DESC:SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L0624 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/06 FULL DESC:SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID PANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN,CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 30 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 159 ------------------------------------------------------------------------------- + SPINAL-CERVICAL-THORACIC-LUMBAR-SACRAL-HALO - ANTERIOR-POSTERIOR-LATERAL ------------------------------------------------------------------------------- L0700 PAC: 170 MAX FEE: $ 1435.51 EFF DATE: 07/01/02 FULL DESC:CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSIS (CTLSO), ANTERIOR- POSTERIOR-LATERAL CONTROL, MOLDED TO PATIENT MODEL (MINERVA TYPE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 L0710 PAC: 170 MAX FEE: $ 1618.23 EFF DATE: 07/01/02 FULL DESC:CTLSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, MOLDED TO PATIENT MODEL, WITH INTERFACE MATERIAL (MINERVA TYPE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 L1001 PAC: 170 MAX FEE: $ 800.00 EFF DATE: 01/01/07 FULL DESC:CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 3 MONTHS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + HALO PROCEDURE ------------------------------------------------------------------------------- L0810 PAC: 170 MAX FEE: $ 1977.37 EFF DATE: 07/01/02 FULL DESC:HALO PROCEDURE; CERVICAL HALO INCORPORATED INTO JACKET VEST POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 L0820 PAC: 170 MAX FEE: $ 960.49 EFF DATE: 07/01/02 FULL DESC:HALO PROCEDURE; CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 160 L0830 PAC: 170 MAX FEE: $ 1080.54 EFF DATE: 07/01/02 FULL DESC:HALO PROCEDURE; CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ADDITIONS TO SPINAL ORTHOSES ------------------------------------------------------------------------------- L0970 PAC: 170 MAX FEE: $ 55.34 EFF DATE: 07/01/02 FULL DESC:THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), CORSET FRONT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0972 PAC: 170 MAX FEE: $ 54.30 EFF DATE: 07/01/02 FULL DESC:LUMBAR-SACRAL-ORTHOSIS (LSO), CORSET FRONT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0974 PAC: 170 MAX FEE: $ 90.32 EFF DATE: 07/01/02 FULL DESC:THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), FULL CORSET POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0976 PAC: 170 MAX FEE: $ 90.32 EFF DATE: 07/01/02 FULL DESC:LUMBAR-SACRAL-ORTHOSIS (LSO), FULL CORSET POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L0978 PAC: 170 MAX FEE: $ 208.80 EFF DATE: 07/01/02 FULL DESC:AXILLARY CRUTCH EXTENSION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 161 L0980 PAC: 170 MAX FEE: $ 7.22 EFF DATE: 07/01/02 FULL DESC:PERITONEAL STRAPS, PAIR POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.50 L0982 PAC: 170 MAX FEE: $ 7.22 EFF DATE: 07/01/02 FULL DESC:STOCKING SUPPORTER GRIPS, SET OF FOUR (4) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.50 L0984 PAC: 170 MAX FEE: $ 47.12 EFF DATE: 07/01/02 FULL DESC:PROTECTIVE BODY SOCK, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 2.00 L0999 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 02/01/99 FULL DESC:ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + SCOLIOSIS PROCEDURES - SCOLIOSIS-CERVICAL-THORACIC-LUMBAR-SACRAL ------------------------------------------------------------------------------- L1000 PAC: 170 MAX FEE: $ 1203.74 EFF DATE: 07/01/02 FULL DESC:CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSES, INCLUDING MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 162 L1005 PAC: 170 MAX FEE: $ 2576.70 EFF DATE: 10/01/03 FULL DESC:TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + CORRECTION PADS ------------------------------------------------------------------------------- L1010 PAC: 170 MAX FEE: $ 48.13 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; AXILLA SLING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1020 PAC: 170 MAX FEE: $ 48.13 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; KYPHOSIS PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1025 PAC: 170 MAX FEE: $ 121.82 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; KYPHOSIS PAD, FLOATING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1030 PAC: 170 MAX FEE: $ 54.30 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; LUMBAR BOLSTER PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1040 PAC: 170 MAX FEE: $ 52.98 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; LUMBAR OR LUMBAR RIB PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 163 L1050 PAC: 170 MAX FEE: $ 60.18 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; STERNAL PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1060 PAC: 170 MAX FEE: $ 54.30 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; THORACIC PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1070 PAC: 170 MAX FEE: $ 50.10 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; TRAPEZE SLING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1080 PAC: 170 MAX FEE: $ 21.93 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; OUTRIGGER POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1085 PAC: 170 MAX FEE: $ 98.86 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1090 PAC: 170 MAX FEE: $ 63.98 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; LUMBAR SLING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 164 L1100 PAC: 170 MAX FEE: $ 104.39 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; RING FLANGE, PLASTIC OR LEATHER POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1110 PAC: 170 MAX FEE: $ 158.70 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1120 PAC: 170 MAX FEE: $ 24.02 EFF DATE: 07/01/02 FULL DESC:ADDITIONS TO CTLSO OR SCOLIOSIS ORTHOSIS; COVER FOR UPRIGHT, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + SCOLIOSIS-THORACIC-LUMBAR-SACRAL (LOW PROFILE) ------------------------------------------------------------------------------- L1200 PAC: 170 MAX FEE: $ 1044.02 EFF DATE: 07/01/02 FULL DESC:THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1210 PAC: 170 MAX FEE: $ 309.56 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); LATERAL THORACIC EXTENSION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 165 L1220 PAC: 170 MAX FEE: $ 142.00 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); ANTERIOR THORACIC EXTENSION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1230 PAC: 170 MAX FEE: $ 361.12 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); MILWAUKEE TYPE SUPERSTRUCTURE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1240 PAC: 170 MAX FEE: $ 77.39 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); LUMBAR DEROTATION PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1250 PAC: 170 MAX FEE: $ 46.92 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); ANTERIOR ASIS PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1260 PAC: 170 MAX FEE: $ 73.90 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); ANTERIOR THORACIC DEROTATION PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1270 PAC: 170 MAX FEE: $ 73.90 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); ABDOMINAL PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 166 L1280 PAC: 170 MAX FEE: $ 74.90 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); RIB GUSSET (ELASTIC), EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L1290 PAC: 170 MAX FEE: $ 65.91 EFF DATE: 07/01/02 FULL DESC:ADDITION TO TLSO, (LOW PROFILE); LATERAL TROCHANTERIC PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + OTHER SCOLIOSIS PROCEDURES ------------------------------------------------------------------------------- L1300 PAC: 170 MAX FEE: $ 1028.37 EFF DATE: 07/01/02 FULL DESC:OTHER SCOLIOSIS PROCEDURE; BODY JACKET MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1310 PAC: 170 MAX FEE: $ 997.02 EFF DATE: 07/01/02 FULL DESC:OTHER SCOLIOSIS PROCEDURE; POST-OPERATIVE BODY JACKET POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 3.00 L1499 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/88 FULL DESC:SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 167 ------------------------------------------------------------------------------- + THORACIC-HIP-KNEE-ANKLE ------------------------------------------------------------------------------- L1500 PAC: 170 MAX FEE: $ 951.00 EFF DATE: 07/01/02 FULL DESC:THORACIC-HIP-KNEE-ANKLE-ORTHOSIS (THKAO); MOBILITY FRAME (NEWINGTON, PARAPODIUM TYPES) POS: 11 12 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 L1510 PAC: 170 MAX FEE: $ 678.61 EFF DATE: 10/01/03 FULL DESC:THORACIC HIP KNEE ANKLE ORTHOSIS; STANDING FRAME, WITH OR WITHOUT TRAY AND ACCESSORIES POS: 11 12 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 L1520 PAC: 170 MAX FEE: $ 1513.82 EFF DATE: 07/01/02 FULL DESC:THKAO, SWIVEL WALKER POS: 11 12 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 YEAR NH: N COPAY: $ 3.00 ------------------------------------------------------------------------------- + LOWER LIMB - HIP-FLEXIBLE ------------------------------------------------------------------------------- L1600 PAC: 170 MAX FEE: $ 63.69 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WITH COVER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT. POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1610 PAC: 170 MAX FEE: $ 30.28 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER ONLY),PERFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 168 L1620 PAC: 170 MAX FEE: $ 76.73 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1630 PAC: 170 MAX FEE: $ 135.73 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, SEMI FLEXIBLE (VON ROSEN TYPE), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1640 PAC: 170 MAX FEE: $ 300.95 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS,ABDUCTION CONTROL OF HIP JOINTS, STATIC,PELVIC BAND OR SPREADER BAR, THIGH CUFFS, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1650 PAC: 170 MAX FEE: $ 180.61 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFLED TYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1652 PAC: 170 MAX FEE: $ 286.97 EFF DATE: 10/01/03 FULL DESC:HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT, ANY TYPE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 169 L1660 PAC: 170 MAX FEE: $ 78.31 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1680 PAC: 170 MAX FEE: $ 433.26 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL, ADJUSTABLE HIP MOTION CONTROL, HIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1685 PAC: 170 MAX FEE: $ 689.02 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1686 PAC: 170 MAX FEE: $ 761.91 EFF DATE: 07/01/02 FULL DESC:HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + LEGG PERTHES ------------------------------------------------------------------------------- L1690 PAC: 170 MAX FEE: $ 1502.12 EFF DATE: 07/01/02 FULL DESC:COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION AND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 170 L1700 PAC: 170 MAX FEE: $ 898.91 EFF DATE: 07/01/02 FULL DESC:LEGG PERTHES ORTHOSIS,(TORONTO TYPE), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1710 PAC: 170 MAX FEE: $ 991.82 EFF DATE: 07/01/02 FULL DESC:LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1720 PAC: 170 MAX FEE: $ 749.59 EFF DATE: 07/01/02 FULL DESC:LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM- FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1730 PAC: 170 MAX FEE: $ 674.05 EFF DATE: 07/01/02 FULL DESC:LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1755 PAC: 170 MAX FEE: $ 1298.15 EFF DATE: 07/01/02 FULL DESC:LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 171 ------------------------------------------------------------------------------- + KNEE ------------------------------------------------------------------------------- L1800 PAC: 170 MAX FEE: $ 48.02 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 L1810 PAC: 170 MAX FEE: $ 62.96 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1815 PAC: 170 MAX FEE: $ 74.90 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ELASTIC OR OTHER ELASTIC TYPE MATERIAL WITH CONDYLAR PAD(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1820 PAC: 170 MAX FEE: $ 73.38 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1825 PAC: 170 MAX FEE: $ 29.22 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ELASTIC KNEE CAP, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 172 L1830 PAC: 170 MAX FEE: $ 52.21 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1831 PAC: 170 MAX FEE: $ 105.00 EFF DATE: 01/01/04 FULL DESC:KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED POS: 11 12 31 32 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L1832 PAC: 170 MAX FEE: $ 472.33 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1834 PAC: 170 MAX FEE: $ 445.36 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1836 PAC: 170 MAX FEE: $ 107.40 EFF DATE: 10/01/03 FULL DESC:KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1840 PAC: 170 MAX FEE: $ 355.07 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 173 L1843 PAC: 170 MAX FEE: $ 415.31 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1844 PAC: 170 MAX FEE: $ 599.15 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1845 PAC: 170 MAX FEE: $ 615.12 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1846 PAC: 170 MAX FEE: $ 865.77 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1847 PAC: 170 MAX FEE: $ 446.79 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 174 L1850 PAC: 170 MAX FEE: $ 216.65 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1860 PAC: 170 MAX FEE: $ 698.45 EFF DATE: 07/01/02 FULL DESC:KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2005 PAC: 170 MAX FEE: $ 1710.00 EFF DATE: 01/01/05 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ANKLE-FOOT ------------------------------------------------------------------------------- L1900 PAC: 170 MAX FEE: $ 180.61 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1901 PAC: 170 MAX FEE: $ 14.24 EFF DATE: 10/01/03 FULL DESC:ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 6 MONTHS NH: Y COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 175 L1902 PAC: 170 MAX FEE: $ 76.89 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1904 PAC: 170 MAX FEE: $ 449.36 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1906 PAC: 170 MAX FEE: $ 109.84 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1907 PAC: 170 MAX FEE: $ 313.20 EFF DATE: 01/01/04 FULL DESC:AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1910 PAC: 170 MAX FEE: $ 167.04 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1920 PAC: 170 MAX FEE: $ 210.63 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 176 L1930 PAC: 170 MAX FEE: $ 167.89 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1932 PAC: 170 MAX FEE: $ 400.00 EFF DATE: 07/01/06 FULL DESC:ANKLE FOOT ORTHOSIS, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1940 PAC: 170 MAX FEE: $ 282.93 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1945 PAC: 170 MAX FEE: $ 770.87 EFF DATE: 10/01/03 FULL DESC:ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1950 PAC: 170 MAX FEE: $ 511.57 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1951 PAC: 170 MAX FEE: $ 365.41 EFF DATE: 01/01/04 FULL DESC:ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 177 L1960 PAC: 170 MAX FEE: $ 282.93 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM- FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1970 PAC: 170 MAX FEE: $ 365.41 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1971 PAC: 170 MAX FEE: $ 365.41 EFF DATE: 01/01/04 FULL DESC:ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1980 PAC: 170 MAX FEE: $ 228.64 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR BK ORTHOSIS), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L1990 PAC: 170 MAX FEE: $ 258.91 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR BK ORTHOSIS), CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 178 ------------------------------------------------------------------------------- + HIP-KNEE-ANKLE-FOOT ------------------------------------------------------------------------------- L2000 PAC: 170 MAX FEE: $ 542.89 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR AK ORTHOSIS), CUSTOM- FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2010 PAC: 170 MAX FEE: $ 662.94 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR AK ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2020 PAC: 170 MAX FEE: $ 843.80 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR AK ORTHOSIS), CUSTOM- FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2030 PAC: 170 MAX FEE: $ 769.43 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR AK ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2034 PAC: 170 MAX FEE: $ 1710.44 EFF DATE: 01/01/06 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 179 L2035 PAC: 170 MAX FEE: $ 133.23 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: N COPAY: $ 0.00 L2036 PAC: 170 MAX FEE: $ 1007.55 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + TORSION CONTROL ------------------------------------------------------------------------------- L2040 PAC: 170 MAX FEE: $ 157.78 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2050 PAC: 170 MAX FEE: $ 270.93 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2060 PAC: 170 MAX FEE: $ 365.41 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, BALL BEARING HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 180 L2070 PAC: 170 MAX FEE: $ 88.75 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2080 PAC: 170 MAX FEE: $ 246.90 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2090 PAC: 170 MAX FEE: $ 287.10 EFF DATE: 07/01/02 FULL DESC:HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, BALL BEARING HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + FRACTURE ORTHOSES ------------------------------------------------------------------------------- L2106 PAC: 170 MAX FEE: $ 318.54 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2108 PAC: 170 MAX FEE: $ 798.86 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 181 L2112 PAC: 170 MAX FEE: $ 502.29 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2114 PAC: 170 MAX FEE: $ 524.25 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2116 PAC: 170 MAX FEE: $ 599.15 EFF DATE: 07/01/02 FULL DESC:ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2126 PAC: 170 MAX FEE: $ 913.69 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2128 PAC: 170 MAX FEE: $ 998.58 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2132 PAC: 170 MAX FEE: $ 698.00 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 182 L2134 PAC: 170 MAX FEE: $ 730.81 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2136 PAC: 170 MAX FEE: $ 998.58 EFF DATE: 07/01/02 FULL DESC:KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ADDITIONS TO FRACTURE ORTHOSIS ------------------------------------------------------------------------------- L2180 PAC: 170 MAX FEE: $ 95.87 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; PLASTIC SHOE INSERT, WITH ANKLE JOINTS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2182 PAC: 170 MAX FEE: $ 69.91 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; DROP LOCK KNEE JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2184 PAC: 170 MAX FEE: $ 74.13 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; LIMITED MOTION KNEE JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 183 L2186 PAC: 170 MAX FEE: $ 99.86 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2188 PAC: 170 MAX FEE: $ 187.74 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; QUADRILATERAL BRIM POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2190 PAC: 170 MAX FEE: $ 58.92 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; WAIST BELT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2192 PAC: 170 MAX FEE: $ 304.56 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS; HIP JOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + ADDITIONS TO LOWER EXTREMITY ORTHOSIS - ADDITIONS-SHOE-ANKLE-SHIN-KNEE ------------------------------------------------------------------------------- L2200 PAC: 170 MAX FEE: $ 44.25 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; LIMITED ANKLE MOTION, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 184 L2210 PAC: 170 MAX FEE: $ 34.54 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2220 PAC: 170 MAX FEE: $ 44.25 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2230 PAC: 170 MAX FEE: $ 66.20 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2232 PAC: 170 MAX FEE: $ 60.00 EFF DATE: 01/01/05 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 L2240 PAC: 170 MAX FEE: $ 65.88 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; ROUND CALIPER AND PLATE ATTACHMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2250 PAC: 170 MAX FEE: $ 198.37 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 185 L2260 PAC: 170 MAX FEE: $ 90.67 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2270 PAC: 170 MAX FEE: $ 48.13 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; VARUS/VALGUS CORRECTION ("T") STRAP, PADDED/LINED OR MALLEOLUS PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2275 PAC: 170 MAX FEE: $ 90.71 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2280 PAC: 170 MAX FEE: $ 313.20 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; MOLDED INNER BOOT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2300 PAC: 170 MAX FEE: $ 151.39 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2310 PAC: 170 MAX FEE: $ 78.31 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; ABDUCTION BAR-STRAIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 186 L2320 PAC: 170 MAX FEE: $ 313.20 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2330 PAC: 170 MAX FEE: $ 469.81 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2335 PAC: 170 MAX FEE: $ 184.74 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; ANTERIOR SWING BAND POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2340 PAC: 170 MAX FEE: $ 318.43 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2350 PAC: 170 MAX FEE: $ 480.25 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FOR "PTB" "AFO" ORTHOSES) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2360 PAC: 170 MAX FEE: $ 32.35 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; EXTENDED STEEL SHANK POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 187 L2370 PAC: 170 MAX FEE: $ 322.54 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; PATTEN BOTTOM POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2375 PAC: 170 MAX FEE: $ 69.91 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2380 PAC: 170 MAX FEE: $ 79.89 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2385 PAC: 170 MAX FEE: $ 101.55 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2387 PAC: 170 MAX FEE: $ 119.83 EFF DATE: 01/01/06 FULL DESC:ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FAB RICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 3.00 L2390 PAC: 170 MAX FEE: $ 104.85 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; OFFSET KNEE JOINT, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 188 L2395 PAC: 170 MAX FEE: $ 119.83 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2397 PAC: 170 MAX FEE: $ 84.95 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L5685 PAC: 170 MAX FEE: $ 85.00 EFF DATE: 07/01/06 FULL DESC:ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/ SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ADDITIONS TO STRAIGHT OR OFFSET KNEE JOINTS ------------------------------------------------------------------------------- L2405 PAC: 170 MAX FEE: $ 60.96 EFF DATE: 07/01/02 FULL DESC:ADDITION TO KNEE JOINT, DROP LOCK, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2415 PAC: 170 MAX FEE: $ 80.23 EFF DATE: 07/01/02 FULL DESC:ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM (BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 189 L2425 PAC: 170 MAX FEE: $ 94.67 EFF DATE: 07/01/02 FULL DESC:ADDITION TO KNEE JOINT; DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2430 PAC: 170 MAX FEE: $ 94.67 EFF DATE: 07/01/02 FULL DESC:ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT. POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2492 PAC: 170 MAX FEE: $ 104.85 EFF DATE: 07/01/02 FULL DESC:ADDITION TO KNEE JOINT; LIFT LOOP FOR DROP LOCK RING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + ADDITIONS-THIGH/WEIGHT BEARING - GLUTEAL/ISCHIAL WEIGHT ------------------------------------------------------------------------------- L2500 PAC: 170 MAX FEE: $ 273.53 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; GLUTEAL/ISCHIAL WEIGHT BEARING, RING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2510 PAC: 170 MAX FEE: $ 391.50 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; QUADRILATERAL BRIM, MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 190 L2520 PAC: 170 MAX FEE: $ 469.81 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; QUADRILATERAL BRIM, CUSTOM FITTING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2525 PAC: 170 MAX FEE: $ 998.58 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; ISCHIAL CONTAINMENT/NARROW M-I BRIM MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2526 PAC: 170 MAX FEE: $ 788.87 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; ISCHIAL CONTAINMENT/NARROW M-I BRIM, CUSTOM FITTED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2530 PAC: 170 MAX FEE: $ 156.62 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; LACER, NON-MOLDED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2540 PAC: 170 MAX FEE: $ 212.98 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; LACER, MOLDED TO PATIENT MODEL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2550 PAC: 170 MAX FEE: $ 299.56 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING; HIGH ROLL CUFF POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 191 ------------------------------------------------------------------------------- + ADDITIONS-PELVIC AND THORACIC CONTROL ------------------------------------------------------------------------------- L2570 PAC: 170 MAX FEE: $ 73.08 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE TWO POSITION JOINT; EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2580 PAC: 170 MAX FEE: $ 65.79 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; PELVIC SLING POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2600 PAC: 170 MAX FEE: $ 252.65 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUST BEARING; FREE, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2610 PAC: 170 MAX FEE: $ 132.59 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE OR TRUST BEARING; LOCK, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2620 PAC: 170 MAX FEE: $ 254.64 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; HIP JOINT, HEAVY DUTY, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 192 L2622 PAC: 170 MAX FEE: $ 396.09 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; HIP JOINT, ADJUSTABLE FLEXION, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2624 PAC: 170 MAX FEE: $ 468.33 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; HIP JOINT, ADJUSTABLE FLEXION, EXTENSION, ABDUCTION CONTROL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2627 PAC: 170 MAX FEE: $ 1164.34 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; PLASTIC, MOLDED TO PATIENT MODEL, RECIPROCATING HIP JOINT AND CABLES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2628 PAC: 170 MAX FEE: $ 1258.22 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; METAL FRAME, RECIPROCATING HIP JOINT AND CABLES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2630 PAC: 170 MAX FEE: $ 125.28 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; BAND AND BELT, UNILATERAL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2640 PAC: 170 MAX FEE: $ 177.49 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC CONTROL; BAND AND BELT, BILATERAL POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 193 L2650 PAC: 170 MAX FEE: $ 66.30 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL; GLUTEAL PAD, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2660 PAC: 170 MAX FEE: $ 78.31 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; THORACIC CONTROL, THORACIC BAND POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2670 PAC: 170 MAX FEE: $ 73.08 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; THORACIC CONTROL, PARASPINAL UPRIGHTS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2680 PAC: 170 MAX FEE: $ 67.87 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY; THORACIC CONTROL, LATERAL SUPPORT UPRIGHTS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + ADDITIONS-GENERAL - LOWER EXTREMITY ------------------------------------------------------------------------------- L2750 PAC: 170 MAX FEE: $ 24.02 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; PLATING CHROME OR NICKEL, PER BAR POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 194 L2755 PAC: 170 MAX FEE: $ 101.50 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2760 PAC: 170 MAX FEE: $ 33.67 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; EXTENSION, PER EXTENSION PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2768 PAC: 170 MAX FEE: $ 104.88 EFF DATE: 10/01/03 FULL DESC:ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L2770 PAC: 170 MAX FEE: $ 31.33 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; ANY MATERIAL, PER BAR OR JOINT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2780 PAC: 170 MAX FEE: $ 10.44 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; NON-CORROSIVE FINISH, PER BAR POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2785 PAC: 170 MAX FEE: $ 50.79 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; DROP LOCK RETAINER, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 195 L2795 PAC: 170 MAX FEE: $ 55.75 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; KNEE CONTROL, FULL KNEECAP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2800 PAC: 170 MAX FEE: $ 72.91 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2810 PAC: 170 MAX FEE: $ 62.41 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; KNEE CONTROL, CONDYLAR PAD POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER 2 YEARS NH: Y COPAY: $ 0.00 L2820 PAC: 170 MAX FEE: $ 105.85 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2830 PAC: 170 MAX FEE: $ 81.89 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2840 PAC: 170 MAX FEE: $ 27.95 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 196 L2850 PAC: 170 MAX FEE: $ 39.94 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY ORTHOSIS; FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 L2860 PAC: 170 MAX FEE: $ 297.07 EFF DATE: 07/01/02 FULL DESC:ADDITION TO LOWER EXTREMITY JOINT, KNEE, OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 0.00 L2999 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/88 FULL DESC:LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: Y PA REQ: $ 150.00 LIFE EXP: NH: Y COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 197 ******************************************************************************* ORTHOPEDIC SHOES, MODIFICATIONS, TRANSFERS ******************************************************************************* ------------------------------------------------------------------------------- + INSERT, REMOVABLE, MOLDED TO PATIENT MODEL ------------------------------------------------------------------------------- L3000 PAC: 170 MAX FEE: $ 123.19 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; "UCB" TYPE, BERKELEY SHELL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3001 PAC: 170 MAX FEE: $ 5.26 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; SPENCO, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.50 L3002 PAC: 170 MAX FEE: $ 57.42 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; PLASTAZOTE OR EQUAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3003 PAC: 170 MAX FEE: $ 187.93 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; SILICONE GEL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 198 L3010 PAC: 170 MAX FEE: $ 102.32 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; LONGITUDINAL ARCH SUPPORT, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3020 PAC: 170 MAX FEE: $ 90.83 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL; LONGITUDINAL/METATARSAL SUPPORT, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3030 PAC: 170 MAX FEE: $ 91.45 EFF DATE: 07/01/02 FULL DESC:FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3031 PAC: 170 MAX FEE: $ 101.50 EFF DATE: 01/01/04 FULL DESC:FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ARCH SUPPORT, REMOVABLE, PREMOLDED ------------------------------------------------------------------------------- L3040 PAC: 170 MAX FEE: $ 12.63 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED; LONGITUDINAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 199 L3050 PAC: 170 MAX FEE: $ 15.78 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED; METATARSAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 L3060 PAC: 170 MAX FEE: $ 52.21 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED; LONGITUDINAL/ METATARSAL, EACH ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE ------------------------------------------------------------------------------- L3070 PAC: 170 MAX FEE: $ 13.57 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE; LONGITUDINAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 L3080 PAC: 170 MAX FEE: $ 18.79 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE; METATARSAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 1.00 L3090 PAC: 170 MAX FEE: $ 52.21 EFF DATE: 07/01/02 FULL DESC:FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE; LONGITUDINAL/METATARSAL, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 200 L3100 PAC: 170 MAX FEE: $ 37.95 EFF DATE: 07/01/02 FULL DESC:HALLUS-VALGUS NIGHT DYNAMIC SPLINT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 ------------------------------------------------------------------------------- + ABDUCTION AND ROTATION BARS ------------------------------------------------------------------------------- L3140 PAC: 170 MAX FEE: $ 57.42 EFF DATE: 07/01/02 FULL DESC:FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 3.00 L3150 PAC: 170 MAX FEE: $ 34.94 EFF DATE: 07/01/02 FULL DESC:FOOT, ABDUCTION ROTATION BAR, WITHOUT SHOES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 L3170 PAC: 170 MAX FEE: $ 44.91 EFF DATE: 07/01/02 FULL DESC:FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 2.00 ------------------------------------------------------------------------------- + ORTHOPEDIC FOOTWEAR ------------------------------------------------------------------------------- L3201 PAC: 170 MAX FEE: $ 88.88 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 201 L3202 PAC: 170 MAX FEE: $ 95.87 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 L3203 PAC: 170 MAX FEE: $ 101.86 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 3.00 L3204 PAC: 170 MAX FEE: $ 75.89 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 L3206 PAC: 170 MAX FEE: $ 69.91 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 L3207 PAC: 170 MAX FEE: $ 75.89 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 3.00 L3208 PAC: 170 MAX FEE: $ 34.44 EFF DATE: 07/01/02 FULL DESC:SURGICAL BOOT, EACH; INFANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 202 L3209 PAC: 170 MAX FEE: $ 34.44 EFF DATE: 07/01/02 FULL DESC:SURGICAL BOOT, EACH; CHILD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 0.00 L3211 PAC: 170 MAX FEE: $ 34.44 EFF DATE: 07/01/02 FULL DESC:SURGICAL BOOT, EACH; JUNIOR POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 3 PER YEAR NH: Y COPAY: $ 2.00 L3212 PAC: 170 MAX FEE: $ 95.87 EFF DATE: 07/01/02 FULL DESC:BENESCH BOOT, PAIR; INFANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 3 PAIRS PER YEAR NH: Y COPAY: $ 0.00 L3213 PAC: 170 MAX FEE: $ 95.87 EFF DATE: 07/01/02 FULL DESC:BENESCH BOOT, PAIR; CHILD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 3 PAIRS PER YEAR NH: Y COPAY: $ 0.00 L3214 PAC: 170 MAX FEE: $ 88.88 EFF DATE: 07/01/02 FULL DESC:BENESCH BOOT, PAIR; JUNIOR POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 PAIRS PER YEAR NH: Y COPAY: $ 3.00 L3215 PAC: 170 MAX FEE: $ 53.43 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 203 L3216 PAC: 170 MAX FEE: $ 69.90 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3217 PAC: 170 MAX FEE: $ 74.90 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3219 PAC: 170 MAX FEE: $ 58.42 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3221 PAC: 170 MAX FEE: $ 74.89 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3222 PAC: 170 MAX FEE: $ 79.90 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3224 PAC: 170 MAX FEE: $ 53.44 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 204 L3225 PAC: 170 MAX FEE: $ 58.42 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC FOOTWEAR, MANS SHOE, OXFORD USED AS AN INTEGRAL PART OF BRACE. POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 L3230 PAC: 170 MAX FEE: $ 199.72 EFF DATE: 01/01/06 FULL DESC:ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 2 SHOES PER YEAR NH: Y COPAY: $ 3.00 L3250 PAC: 170 MAX FEE: $ 298.56 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 L3251 PAC: 170 MAX FEE: $ 261.01 EFF DATE: 07/01/02 FULL DESC:FOOT, SHOE MOLDED TO PATIENT MODEL; SILICONE SHOE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 L3252 PAC: 170 MAX FEE: $ 313.20 EFF DATE: 07/01/02 FULL DESC:FOOT, SHOE MOLDED TO PATIENT MODEL; PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 L3253 PAC: 170 MAX FEE: $ 64.91 EFF DATE: 07/01/02 FULL DESC:FOOT, MOLDED SHOE, PLASTAZOTE (OR SIMILAR), CUSTOM FITTED, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 205 L3254 PAC: 170 MAX FEE: $ 41.76 EFF DATE: 07/01/02 FULL DESC:NON-STANDARD SIZE OR WIDTH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 2.00 L3255 PAC: 170 MAX FEE: $ 34.94 EFF DATE: 07/01/02 FULL DESC:NON-STANDARD SIZE OR LENGTH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 2.00 L3257 PAC: 170 MAX FEE: $ 44.94 EFF DATE: 07/01/02 FULL DESC:ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 0.00 L3260 PAC: 170 MAX FEE: $ 99.17 EFF DATE: 07/01/02 FULL DESC:SURGICAL BOOT/SHOE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: Y LIFE EXP: 1 PER YEAR NH: Y COPAY: $ 3.00 ------------------------------------------------------------------------------- + SHOE MODIFICATION - LIFTS ------------------------------------------------------------------------------- L3300 PAC: 170 MAX FEE: $ 34.94 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; HEEL, TAPERED TO METATARSAL, PER INCH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L3310 PAC: 170 MAX FEE: $ 49.93 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; HEEL AND SOLE, NEOPRENE, PER INCH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 206 L3320 PAC: 170 MAX FEE: $ 33.92 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; HEEL AND SOLE, CORK, PER INCH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L3330 PAC: 170 MAX FEE: $ 44.94 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; METAL EXTENSION (SKATE) POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L3332 PAC: 170 MAX FEE: $ 29.95 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L3334 PAC: 170 MAX FEE: $ 46.92 EFF DATE: 07/01/02 FULL DESC:LIFT, ELEVATION; HEEL, PER INCH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + SHOE MODIFICATION - WEDGES ------------------------------------------------------------------------------- L3340 PAC: 170 MAX FEE: $ 35.24 EFF DATE: 07/01/02 FULL DESC:HEEL WEDGE, SACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3350 PAC: 170 MAX FEE: $ 14.98 EFF DATE: 07/01/02 FULL DESC:HEEL WEDGE, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 207 L3360 PAC: 170 MAX FEE: $ 24.96 EFF DATE: 07/01/02 FULL DESC:SOLE WEDGE; OUTSIDE SOLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3370 PAC: 170 MAX FEE: $ 39.94 EFF DATE: 07/01/02 FULL DESC:SOLE WEDGE; BETWEEN SOLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3380 PAC: 170 MAX FEE: $ 44.94 EFF DATE: 07/01/02 FULL DESC:CLUBFOOT WEDGE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3390 PAC: 170 MAX FEE: $ 39.94 EFF DATE: 07/01/02 FULL DESC:OUTFLARE WEDGE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3400 PAC: 170 MAX FEE: $ 34.94 EFF DATE: 07/01/02 FULL DESC:METATARSAL BAR WEDGE; ROCKER POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3410 PAC: 170 MAX FEE: $ 35.49 EFF DATE: 07/01/02 FULL DESC:METATARSAL BAR WEDGE; BETWEEN SOLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 208 L3420 PAC: 170 MAX FEE: $ 47.92 EFF DATE: 07/01/02 FULL DESC:FULL SOLE AND HEEL WEDGE; BETWEEN SOLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + SHOE MODIFICATION - HEELS ------------------------------------------------------------------------------- L3430 PAC: 170 MAX FEE: $ 52.21 EFF DATE: 07/01/02 FULL DESC:HEEL; COUNTER, PLASTIC REINFORCED POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3440 PAC: 170 MAX FEE: $ 36.53 EFF DATE: 07/01/02 FULL DESC:HEEL; COUNTER, LEATHER REINFORCED POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3450 PAC: 170 MAX FEE: $ 69.91 EFF DATE: 07/01/02 FULL DESC:HEEL; SACH CUSHION TYPE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y COPAY: $ 0.00 L3455 PAC: 170 MAX FEE: $ 9.92 EFF DATE: 07/01/02 FULL DESC:HEEL; NEW LEATHER, STANDARD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 L3460 PAC: 170 MAX FEE: $ 17.23 EFF DATE: 07/01/02 FULL DESC:HEEL; NEW RUBBER, STANDARD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 209 L3465 PAC: 170 MAX FEE: $ 21.97 EFF DATE: 07/01/02 FULL DESC:HEEL; THOMAS WITH WEDGE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: Y CO