Provider Alert! Authorization update for orthoses devices and related services
Attention: DME providers, orthopedists, podiatrists, PCPs
Effective Date: September 5, 2020
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers of the authorization requirements for custom fitted orthoses devices. Certain prefabricated orthoses devices for acute injury do not require a prior authorization. Those codes are available in the second table.
Custom fitted orthosis for chronic medical conditions will require a prior authorization per table below beginning September 4, 2020. For these devices, TCHP will follow criteria listed in the most recent Texas Medicaid Provider Procedures Manual.
Reference: http://www.tmhp.com/manuals_pdf/tmppm/tmppm_living_manual_current/2_DME_and_Supplies.pdf
Sec 2.2.19 Orthotic Services (CCP)
| Code | Description of Codes |
| L2280 | Addition to lower extremity, molded inner boot |
| L1960 | Ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated |
| L1907 | Ankle orthosis (AO), supramalleolar with straps, with or without interface/pads, custom fabricated |
| L1970 | Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated |
| L2275 | Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined |
| L3000 | Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each (For Podiatry) |
| L1499 | Spinal orthosis, not otherwise specified |
| L2999 | Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each |
| L2036 | Knee-ankle-foot orthosis (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
| L1945 | Ankle-foot orthosis (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated |
| L3999 | Upper limb orthosis, not otherwise specified |
| L1200 | Thoracic-lumbar-sacral orthosis (TLSO), inclusive of furnishing initial orthosis only |
| L1932 | Ankle-foot orthosis (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment |
| L0456 | Thoracic-lumbar-sacral orthosis (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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L2820 | Addition to lower extremity orthosis, soft interface for molded plastic, below knee section |
| L2270 | Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad |
| L2340 | Addition to lower extremity, pretibial shell, molded to patient model |
| L3808 | Wrist-hand-finger orthosis (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment |
| L2840 | Addition to lower extremity orthosis, tibial length sock, fracture or equal, each |
| L3906 | Wrist-hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L2200 | Addition to lower extremity, limited ankle motion, each joint |
| L2861 | Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each |
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment |
| L1832 | Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L0482 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L0452 | Thoracic-lumbar-sacral orthosis (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated |
| L2780 | Addition to lower extremity orthosis, noncorrosive finish, per bar |
| L0999 | Addition to spinal orthosis, not otherwise specified |
| L2037 | Knee-ankle-foot orthosis (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
| L2755 | Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only |
| L1005 | Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment |
| L1940 | Ankle-foot orthosis (AFO), plastic or other material, custom fabricated |
| L0484 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L2220 | Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint |
| L0486 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated |
| L3760 | Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1300 | Other scoliosis procedure, body jacket molded to patient model |
| L3206 | Orthopedic shoe, hightop with supinator or pronator, child |
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment |
| L1210 | Addition to thoracic-lumbar-sacral orthosis (TLSO), (low profile), lateral thoracic extension |
| L3807 | Wrist-hand-finger orthosis (WHFO), without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L3010 | Foot insert, removable, molded to patient model, longitudinal arch support, each |
| L0638 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated |
| L2210 | Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint |
| L3020 | Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each |
| L2640 | Addition to lower extremity, pelvic control, band and belt, bilateral |
| L3310 | Lift, elevation, heel and sole, neoprene, per in |
| L3905 | Wrist-hand orthosis (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L2570 | Addition to lower extremity, pelvic control, hip joint, Clevis type two-position joint, each |
| L2795 | Addition to lower extremity orthosis, knee control, full kneecap |
| L1820 | Knee orthosis (KO), elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment |
| L1930 | Ankle-foot orthosis (AFO), plastic or other material, prefabricated, includes fitting and adjustment |
| L0464 | Thoracic-lumbar-sacral orthosis (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 overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L2768 | Orthotic side bar disconnect device, per bar |
| L2430 | Addition to knee joint, ratchet lock for active and progressive knee extension, each joint |
| L2040 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated |
| L1845 | Knee orthosis (KO), 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L2350 | Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses) |
| L0454 | Thoracic-lumbar-sacral orthosis (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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1686 | Hip orthosis (HO), abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment |
| L2114 | Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment |
| L2830 | Addition to lower extremity orthosis, soft interface for molded plastic, above knee section |
| L1220 | Addition to thoracic-lumbar-sacral orthosis (TLSO), (low profile), anterior thoracic extension |
| L1950 | Ankle-foot orthosis (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated |
| L2405 | Addition to knee joint, drop lock, each |
| L1290 | Addition to thoracic-lumbar-sacral orthosis (TLSO), (low profile), lateral trochanteric pad |
| L2620 | Addition to lower extremity, pelvic control, hip joint, heavy-duty, each |
| L3919 | Hand orthosis (HO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L3350 | Heel wedge |
| L2387 | Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot orthosis (KAFO), each joint |
| L3060 | Foot, arch support, removable, premolded, longitudinal/metatarsal, each |
| L1240 | Addition to thoracic-lumbar-sacral orthosis (TLSO), (low profile), lumbar derotation pad |
| L3913 | Hand-finger orthosis (HFO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
| L1060 | Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, thoracic pad |
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment |
| L3203 | Orthopedic shoe, Oxford with supinator or pronator, junior |
| L3995 | Addition to upper extremity orthosis, sock, fracture or equal, each |
| L1600 | Hip orthosis (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L2760 | Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) |
| L1951 | Ankle-foot orthosis (AFO), spiral, (Institute of rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment |
| L3332 | Lift, elevation, inside shoe, tapered, up to one-half in |
| L3320 | Lift, elevation, heel and sole, cork, per in |
| L0630 | Lumbar-sacral orthosis (LSO), 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1040 | Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, lumbar or lumbar rib pad |
| L2810 | Addition to lower extremity orthosis, knee control, condylar pad |
| L3207 | Orthopedic shoe, hightop with supinator or pronator, junior |
| L1080 | Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, outrigger |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) |
| L3540 | Orthopedic shoe addition, sole, full |
| L3400 | Metatarsal bar wedge, rocker |
| L3300 | Lift, elevation, heel, tapered to metatarsals, per in |
| L3334 | Lift, elevation, heel, per in |
| L2785 | Addition to lower extremity orthosis, drop lock retainer, each |
| L4392 | Replacement, soft interface material, static AFO |
| L2600 | Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each |
| L2540 | Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model |
| L1100 | Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, ring flange, plastic or leather |
| L2112 | Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment |
Prefabricated orthosis for acute injury diagnosis do not require prior authorization per the table below:
| Code | Description of Codes |
| L3670 | Shoulder orthosis (SO), acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf |
| L4387 | Walking boot, nonpneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf |
| L1833 | Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf |
| L4361 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf |
| L3908 | Wrist-hand orthosis (WHO), wrist extension control cock-up, nonmolded, prefabricated, off-the-shelf |
| L3809 | Wrist-hand-finger orthosis (WHFO), without joint(s), prefabricated, off-the-shelf, any type |
| L1830 | Knee orthosis (KO), immobilizer, canvas longitudinal, prefabricated, off-the-shelf |
| L3260 | Surgical boot/shoe, each |
| L4350 | Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf |
| L1812 | Knee orthosis (KO), elastic with joints, prefabricated, off-the-shelf |
| L1902 | Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf |
| L3761 | Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf |
| L4360 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L4397 | Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf |
| L4386 | Walking boot, nonpneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L0625 | 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, off-the-shelf |
| L3762 | Elbow orthosis (EO), rigid, without joints, includes soft interface material, prefabricated, off-the-shelf |
| L0648 | Lumbar-sacral orthosis (LSO), 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, off-the-shelf |
| L0172 | Cervical, collar, semi-rigid thermoplastic foam, two piece, prefabricated, off-the-shelf |
| L0984 | Protective body sock, prefabricated, off-the-shelf, each |
| L0457 | Thoracic-lumbar-sacral orthosis (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, off-the-shelf |
| L3710 | Elbow orthosis (EO), elastic with metal joints, prefabricated, off-the-shelf |
| L4370 | Pneumatic full leg splint, prefabricated, off-the-shelf |
| L3170 | Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each |
| L3660 | Shoulder orthosis (SO), figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf |
| L0174 | Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension, prefabricated, off-the-shelf |
| L3675 | Shoulder orthosis (SO), vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf |
| L3927 | Finger orthosis (FO), proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf |
| L3912 | Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf |
| L3924 | Hand-finger orthosis (HFO), without joints, may include soft interface, straps, prefabricated, off-the-shelf |
| L1906 | Ankle foot orthosis (AFO), multiligamentous ankle support, prefabricated, off-the-shelf |
| L3100 | Hallus-valgus night dynamic splint, prefabricated, off-the-shelf |
| L0120 | Cervical, flexible, nonadjustable, prefabricated, off-the-shelf (foam collar) |
How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days. To request prior authorization for orthoses and related services, clinical documentation to support the medical necessity for the requested orthoses must be provided.
Medical Services Fax Line – 832-825-8760 or Toll-Free 1-844-473-6860
Next steps for providers: Update their office staff of the new authorization requirements.
Resources:
TCHP prior authorization information
Prior authorization form
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers
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