The allowance for a prefabricated orthoses includes all components provided at the time of initial issue including, but not limited to, soft interfaces, straps, closures, etc. Replacement of components of covered orthoses are covered if the original component is no longer functional due to wear and cannot be repaired. Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered.
Some replacement items have unique HCPCS codes. For example, replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with HCPCS codes L4392 and L4394, respectively. One unit of service of the replacement interface HCPCS code is covered no more often than once every 6 months. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L1499, L2999, or L3999, whichever is applicable. The claim must include a description of the component provided, the reason for replacement, and the HCPCS code or narrative description of the base orthosis.
Note: HCPCS codes L4040-L4055 do not describe replacement soft interfaces used with contracture orthoses. Questions concerning the coding of specific items should be directed to the SADMERC.
Published by Palmetto GBA as the SADMERC, December 4, 2003. Republished by Noridian as the PDAC, August 2008. Republished by Palmetto GBA as the PDAC, January 2019.