Authorization update for orthoses devices and related services

Attention: DME providers, orthopedists, podiatrists, PCPsEffective Date: September 5, 2020Providers 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