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Official Description

Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments
Short Descr Ue fx orth shoul cap forearm
Coverage Carrier Priced
Pricing Indicator(s) 38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings)
MPI A – Not applicable, as HCPCS priced under one methodology
BETOS D1F – Prosthetic/Orthotic devices
TOS Code(s) P – Lump sum purchase of DME, prosthetics, orthotics
Added Date 1/1/2015
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 2
OTS Orthotic No
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
GA Waiver of liability statement issued as required by payer policy, individual case
GO Services delivered under an outpatient occupational therapy plan of care
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KX Requirements specified in the medical policy have been met
Date
Action
Notes
2015-01-01 Added Added
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Description
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Description
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