Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ORT-18 June 2006 TO: Orthotics Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Orthotics Manual (Coverage of Medically Necessary Orthotics to Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover medically necessary orthotic services for eligible members aged 21 years or older (adults). This letter transmits a revised Subchapter 6 of the Orthotics Manual that reflects the new coverage for adults. The revised Subchapter 6 has also been reformatted. Subchapter 6 now lists all covered service codes in alphanumeric order, and includes age restrictions, prior-authorization requirements, limitations, and modifier requirements. The requirements and limitations listed in the attached Subchapter 6 are in addition to all other requirements and conditions of payment in MassHealth regulations at 130 CMR 442.000 and 450.000. Refer to the Centers for Medicare and Medicaid Services (CMS) Web site at www.cms.gov for a full description of the service codes. Providers may submit a request for prior-authorization for medically necessary additional units beyond the specified maximum units. The request must be submitted before the additional units are provided and must be supported by documentation of medical necessity. Please Note: Services identified in the service descriptions of Level II HCPCS service codes as specifically pertaining to infants, children, or juniors are not covered for adults. Orthotic footwear for adults requires prior authorization. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. NEW MATERIAL (The pages listed here contain new or revised language.) Orthotics Manual Pages iv, vi, vii, and 6-1 through 6-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Orthotics Manual Page iv — transmitted by Transmittal Letter ORT-16 Pages vi and 6-1 through 6-12 — transmitted by Transmittal Letter ORT-17 Page viii — transmitted by Transmittal Letter ORT-12 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Orthotics Manual Transmittal Letter ORT-18 Date 07/01/06 4. Program Regulations 442.401: Introduction 4-1 442.402: Definitions 4-1 442.403: Eligible Members 4-3 442.404: Provider Eligibility 4-3 442.405: Provider Responsibility 4-4 442.406: Covered Services 4-4 442.407: Service Limitations 4-4 442.408: Noncovered Services 4-5 442.409: Prescription and Other Documentation Requirements 4-6 442.410: Orthotic and Pedorthic Services and Equipment Provided to Institutionalized Members 4-6 442.411: Repairs of Orthotic and Pedorthic Equipment 4-7 442.412: Prior Authorization 4-7 442.413: Procedure for Requesting Prior Authorization 4-8 442.414: Medicare Coverage 4-8 (130 CMR 442.415 through 442.419 Reserved) 442.420: Payment for Orthotic or Pedorthic Services 4-9 442.421: Individual Consideration 4-9 442.422: Adjusted Acquisition Cost 4-10 442.423: Recordkeeping Requirements 4-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Orthotics Manual Transmittal Letter ORT-18 Date 07/01/06 6. Service Codes Introduction 6-1 Service Codes, Limitations, and Special Requirements 6-1 Appendix A. Directory A1 Appendix B. Enrollment Centers B1 Appendix C. ThirdParty-Liability Codes C1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. REVS/Codes Messages Y-1 Appendix Z. EPSDT Services Laboratory Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Orthotics Manual Transmittal Letter ORT-18 Date 07/01/06 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For orthotics providers, those matters are covered in 130 CMR Chapter 442.000, reproduced as Subchapter 4 in the Orthotics Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("penandink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. 601 Introduction MassHealth pays for the services represented by the codes listed in Section 602 in effect at the time of service, subject to all the conditions and limitations in Subchapter 6 and in MassHealth regulations at 130 CMR 442.000 and 450.000. The provider may request prior authorization (PA) for orthotic services to eligible members, if additional units are medically necessary. Please Note: Service codes that require PA only when the number of units exceeds the limitations for the code in Section 602 are listed as requiring PA “Sometimes.” 602 Service Codes and Limitations Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? A5500 No Sometimes 2 per 12 months RT LT Yes A5501 No Sometimes 2 per 12 months RT LT Yes A5503 No Sometimes 2 per 12 months RT LT Yes A5504 No Sometimes 2 per 12 months RT LT Yes A5506 No Sometimes 2 per 12 months RT LT Yes A5507 No Sometimes 2 per 12 months RT LT Yes A5508 No Sometimes 2 per 12 months RT LT Yes A5509 No Sometimes 12 per 12 months RT LT Yes A5511 No Sometimes 2 per 12 months RT LT Yes L0100 No Sometimes 1 per 12 months -- No L0110 No Sometimes 1 per 12 months -- No L0120 No Sometimes 2 per 12 months -- No L0130 No Sometimes 1 per 12 months -- No L0150 No Sometimes 1 per 12 months -- No L0160 No Sometimes 1 per 12 months -- No L0170 No Sometimes 1 per 12 months -- No L0172 No Sometimes 2 per 12 months -- No L0174 No Sometimes 2 per 12 months -- No L0180 No Sometimes 1 per 12 months -- No L0190 No Sometimes 1 per 12 months -- No L0200 No Sometimes 1 per 12 months -- No L0210 Yes Sometimes 1 per 12 months -- No L0220 No Sometimes 1 per 12 months -- No L0450 No Sometimes 1 per 12 months -- No L0452 No Sometimes 1 per 12 months -- No L0454 No Sometimes 1 per 12 months -- No L0456 No Sometimes 1 per 12 months -- No L0458 No Sometimes 1 per 12 months -- No L0460 No Sometimes 1 per 12 months -- No L0470 No Sometimes 1 per 12 months -- No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L0472 No Sometimes 1 per 12 months -- No L0474 No Sometimes 1 per 12 months -- No L0476 No Sometimes 1 per 12 months -- No L0478 No Sometimes 1 per 12 months -- No L0480 No Sometimes 1 per 12 months -- No L0482 No Sometimes 1 per 12 months -- No L0484 No Sometimes 1 per 12 months -- No L0486 No Sometimes 1 per 12 months -- No L0488 No Sometimes 1 per 12 months -- No L0490 No Sometimes 1 per 12 months -- No L0500 No Sometimes 1 per 12 months RT LT No L0510 No Sometimes 1 per 12 months RT LT No L0515 No Sometimes 1 per 12 months RT LT No L0520 No Sometimes 1 per 12 months RT LT No L0530 No Sometimes 1 per 12 months RT LT No L0540 No Sometimes 1 per 12 months RT LT No L0550 No Sometimes 1 per 12 months -- No L0560 No Sometimes 1 per 12 months -- No L0561 No Sometimes 1 per 12 months -- No L0565 No Sometimes 1 per 12 months -- No L0600 No Sometimes 1 per 12 months -- No L0610 No Sometimes 1 per 12 months -- No L0620 No Sometimes 1 per 12 months -- No L0700 No Sometimes 1 per 12 months -- No L0710 No Sometimes 1 per 12 months -- No L0810 No Sometimes 1 per 12 months -- No L0820 No Sometimes 1 per 12 months -- No L0830 No Sometimes 1 per 12 months -- No L0860 No Sometimes 1 per 12 months -- No L0960 No Sometimes 4 per 12 months -- No L0970 No Sometimes 1 per 12 months -- No L0972 No Sometimes 1 per 12 months -- No L0974 No Sometimes 1 per 12 months -- No L0976 No Sometimes 1 per 12 months -- No L0978 No Sometimes 1 per 12 months -- No L0980 No Sometimes 1 per 12 months -- No L0982 No Sometimes 2 per 12 months -- No L0984 No Sometimes 3 per 6 months -- No L0999 No Sometimes 2 per 12 months -- No L1000 No Sometimes 1 per 12 months RT LT No L1005 No Sometimes 1 per 12 months RT LT No L1010 No Sometimes 2 per 12 months RT LT No L1020 No Sometimes 2 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L1025 No Sometimes 2 per 12 months RT LT No L1030 No Sometimes 2 per 12 months RT LT No L1040 No Sometimes 2 per 12 months RT LT No L1050 No Sometimes 2 per 12 months RT LT No L1060 No Sometimes 2 per 12 months RT LT No L1070 No Sometimes 2 per 12 months RT LT No L1080 No Sometimes 2 per 12 months RT LT No L1085 No Sometimes 2 per 12 months RT LT No L1090 No Sometimes 2 per 12 months RT LT No L1100 No Sometimes 2 per 12 months RT LT No L1110 No Sometimes 2 per 12 months RT LT No L1120 No Sometimes 4 per 12 months RT LT No L1200 No Sometimes 1 per 12 months -- No L1210 No Sometimes 1 per 12 months -- No L1220 No Sometimes 1 per 12 months -- No L1230 No Sometimes 1 per 12 months -- No L1240 No Sometimes 2 per 12 months -- No L1250 No Sometimes 2 per 12 months -- No L1260 No Sometimes 2 per 12 months -- No L1270 No Sometimes 2 per 12 months -- No L1280 No Sometimes 2 per 12 months -- No L1290 No Sometimes 2 per 12 months -- No L1300 No Sometimes 1 per 12 months -- No L1310 No Sometimes 1 per 12 months -- No L1499 No Sometimes -- No L1500 No Sometimes 1 per 12 months -- No L1510 No Sometimes 1 per 12 months -- No L1520 No Sometimes 1 per 12 months -- No L1600 Yes Sometimes 2 per 12 months -- No L1610 Yes Sometimes 2 per 12 months -- No L1620 Yes Sometimes 2 per 12 months -- No L1630 Yes Sometimes 2 per 12 months -- No L1640 Yes Sometimes 2 per 12 months -- No L1650 Yes Sometimes 2 per 12 months -- No L1652 Yes Sometimes 1 per 12 months -- No L1660 Yes Sometimes 2 per 12 months -- No L1680 Yes Sometimes 1 per 12 months -- No L1685 Yes Sometimes 1 per 12 months -- No L1686 Yes Sometimes 1 per 12 months -- No L1690 Yes Sometimes 2 per 12 months -- No L1700 Yes Sometimes 2 per 12 months -- No L1710 Yes Sometimes 2 per 12 months -- No L1720 Yes Sometimes 2 per 12 months -- No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L1730 Yes Sometimes 2 per 12 months -- No L1750 No Sometimes 2 per 12 months RT LT No L1755 No Sometimes 2 per 12 months RT LT No L1800 No Sometimes 2 per 12 months RT LT No L1810 No Sometimes 2 per 12 months RT LT No L1815 No Sometimes 2 per 12 months RT LT No L1820 No Sometimes 2 per 12 months RT LT No L1825 No Sometimes 2 per 12 months RT LT No L1830 No Sometimes 2 per 12 months RT LT No L1832 No Sometimes 2 per 12 months RT LT No L1834 No Sometimes 2 per 12 months RT LT No L1836 No Sometimes 2 per 12 months RT LT No L1843 No Sometimes 2 per 12 months RT LT No L1844 No Sometimes 2 per 12 months RT LT No L1845 No Sometimes 2 per 12 months RT LT No L1846 No Sometimes 2 per 12 months RT LT No L1847 No Sometimes 2 per 12 months RT LT No L1850 No Sometimes 2 per 12 months RT LT No L1855 No Sometimes 2 per 12 months RT LT No L1858 No Sometimes 2 per 12 months RT LT No L1860 No Sometimes 2 per 12 months RT LT No L1870 No Sometimes 2 per 12 months RT LT No L1880 No Sometimes 2 per 12 months RT LT No L1885 No Sometimes 2 per 12 months RT LT No L1900 No Sometimes 2 per 12 months RT LT No L1901 No Sometimes 2 per 12 months RT LT No L1902 No Sometimes 2 per 12 months RT LT No L1904 No Sometimes 2 per 12 months RT LT No L1906 No Sometimes 2 per 12 months RT LT No L1910 No Sometimes 2 per 12 months RT LT No L1920 No Sometimes 2 per 12 months RT LT No L1930 No Sometimes 2 per 12 months RT LT No L1940 No Sometimes 2 per 12 months RT LT No L1945 No Sometimes 2 per 12 months RT LT No L1950 No Sometimes 2 per 12 months RT LT No L1960 No Sometimes 2 per 12 months RT LT No L1970 No Sometimes 2 per 12 months RT LT No L1980 No Sometimes 2 per 12 months RT LT No L1990 No Sometimes 2 per 12 months RT LT No L2000 No Sometimes 2 per 12 months RT LT No L2010 No Sometimes 2 per 12 months RT LT No L2020 No Sometimes 2 per 12 months RT LT No L2030 No Sometimes 2 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L2035 No Sometimes 2 per 12 months RT LT No L2036 No Sometimes 2 per 12 months RT LT No L2037 No Sometimes 2 per 12 months RT LT No L2038 No Sometimes 2 per 12 months RT LT No L2039 No Sometimes 2 per 12 months RT LT No L2040 No Sometimes 2 per 12 months RT LT No L2050 No Sometimes 1 per 12 months RT LT No L2060 No Sometimes 1 per 12 months RT LT No L2070 No Sometimes 1 per 12 months RT LT No L2080 No Sometimes 2 per 12 months RT LT No L2090 No Sometimes 2 per 12 months RT LT No L2106 No Sometimes 2 per 12 months RT LT No L2108 No Sometimes 2 per 12 months RT LT No L2112 No Sometimes 2 per 12 months RT LT No L2114 No Sometimes 2 per 12 months RT LT No L2116 No Sometimes 2 per 12 months RT LT No L2126 No Sometimes 2 per 12 months RT LT No L2128 No Sometimes 2 per 12 months RT LT No L2132 No Sometimes 2 per 12 months RT LT No L2134 No Sometimes 2 per 12 months RT LT No L2136 No Sometimes 2 per 12 months RT LT No L2180 No Sometimes 2 per 12 months RT LT No L2182 No Sometimes 2 per 12 months RT LT No L2184 No Sometimes 2 per 12 months RT LT No L2186 No Sometimes 2 per 12 months RT LT No L2188 No Sometimes 2 per 12 months RT LT No L2190 No Sometimes 1 per 12 months RT LT No L2192 No Sometimes 2 per 12 months RT LT No L2200 No Sometimes 4 per 12 months RT LT No L2210 No Sometimes 4 per 12 months RT LT No L2220 No Sometimes 4 per 12 months RT LT No L2230 No Sometimes 2 per 12 months RT LT No L2240 No Sometimes 2 per 12 months RT LT No L2250 No Sometimes 2 per 12 months RT LT No L2260 No Sometimes 2 per 12 months RT LT No L2265 No Sometimes 2 per 12 months RT LT No L2270 No Sometimes 4 per 12 months RT LT No L2275 No Sometimes 2 per 12 months RT LT No L2280 No Sometimes 2 per 12 months RT LT No L2300 No Sometimes 2 per 12 months RT LT No L2310 No Sometimes 2 per 12 months RT LT No L2320 No Sometimes 2 per 12 months RT LT No L2330 No Sometimes 2 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L2335 No Sometimes 2 per 12 months RT LT No L2340 No Sometimes 2 per 12 months RT LT No L2350 No Sometimes 2 per 12 months RT LT No L2360 No Sometimes 2 per 12 months RT LT No L2370 No Sometimes 2 per 12 months RT LT No L2375 No Sometimes 4 per 12 months RT LT No L2380 No Sometimes 4 per 12 months RT LT No L2385 No Sometimes 4 per 12 months RT LT No L2390 No Sometimes 4 per 12 months RT LT No L2395 No Sometimes 4 per 12 months RT LT No L2397 No Sometimes 2 per 12 months RT LT No L2405 No Sometimes 4 per 12 months RT LT No L2415 No Sometimes 4 per 12 months RT LT No L2425 No Sometimes 4 per 12 months RT LT No L2430 No Sometimes 4 per 12 months RT LT No L2435 No Sometimes 4 per 12 months RT LT No L2492 No Sometimes 4 per 12 months RT LT No L2500 No Sometimes 2 per 12 months RT LT No L2510 No Sometimes 2 per 12 months RT LT No L2520 No Sometimes 2 per 12 months RT LT No L2526 No Sometimes 2 per 12 months RT LT No L2530 No Sometimes 2 per 12 months RT LT No L2540 No Sometimes 2 per 12 months RT LT No L2550 No Sometimes 2 per 12 months RT LT No L2570 No Sometimes 2 per 12 months RT LT No L2580 No Sometimes 2 per 12 months RT LT No L2600 No Sometimes 2 per 12 months RT LT No L2610 No Sometimes 2 per 12 months RT LT No L2620 No Sometimes 2 per 12 months RT LT No L2622 No Sometimes 2 per 12 months RT LT No L2624 No Sometimes 2 per 12 months RT LT No L2627 No Sometimes 2 per 12 months RT LT No L2628 No Sometimes 2 per 12 months RT LT No L2630 No Sometimes 2 per 12 months RT LT No L2640 No Sometimes 2 per 12 months RT LT No L2650 No Sometimes 2 per 12 months RT LT No L2660 No Sometimes 2 per 12 months RT LT No L2670 No Sometimes 2 per 12 months RT LT No L2680 No Sometimes 2 per 12 months RT LT No L2750 No Sometimes 4 per 12 months RT LT No L2755 No Sometimes 4 per 12 months RT LT No L2760 No Sometimes 4 per 12 months RT LT No L2768 No Sometimes 4 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L2770 No Sometimes 8 per 12 months RT LT No L2780 No Sometimes 8 per 12 months RT LT No L2785 No Sometimes 4 per 12 months RT LT No L2795 No Sometimes 2 per 12 months RT LT No L2800 No Sometimes 2 per 12 months RT LT No L2810 No Sometimes 2 per 12 months RT LT No L2820 No Sometimes 4 per 12 months RT LT No L2830 No Sometimes 4 per 12 months RT LT No L2840 No Sometimes 6 per 12 months RT LT No L2850 No Sometimes 6 per 12 months RT LT No L2860 No Sometimes 2 per 12 months RT LT No L2999 No Sometimes 4 per 12 months RT LT No L3000 No Sometimes 4 per 12 months RT LT No L3000 No Sometimes 4 per 12 months RT LT No L3001 No Sometimes 4 per 12 months RT LT No L3002 No Sometimes 4 per 12 months RT LT No L3003 No Sometimes 4 per 12 months RT LT No L3010 No Sometimes 4 per 12 months RT LT No L3020 No Sometimes 4 per 12 months RT LT No L3030 No Sometimes 4 per 12 months RT LT No L3040 No Sometimes 4 per 12 months RT LT No L3050 No Sometimes 4 per 12 months RT LT No L3060 No Sometimes 4 per 12 months RT LT No L3070 No Sometimes 4 per 12 months RT LT No L3080 No Sometimes 4 per 12 months RT LT No L3090 No Sometimes 4 per 12 months RT LT No L3100 No Sometimes 2 per 12 months RT LT No L3140 Yes Sometimes 2 per 12 months RT LT No L3150 Yes Sometimes 2 per 12 months RT LT No L3160 Yes Sometimes 2 per 12 months RT LT No L3170 No Sometimes 2 per 12 months RT LT No L3201 Yes Sometimes 4 per 12 months RT LT Yes L3202 Yes Sometimes 4 per 12 months RT LT Yes L3203 Yes Sometimes 4 per 12 months RT LT Yes L3204 Yes Sometimes 4 per 12 months RT LT Yes L3206 Yes Sometimes 4 per 12 months RT LT Yes L3207 Yes Sometimes 4 per 12 months RT LT Yes L3208 Yes Sometimes 4 per 12 months RT LT Yes L3209 Yes Sometimes 4 per 12 months RT LT Yes L3211 Yes Sometimes 4 per 12 months RT LT Yes L3212 Yes Sometimes 2 per 12 months RT LT Yes L3213 Yes Sometimes 2 per 12 months RT LT Yes L3214 Yes Sometimes 2 per 12 months RT LT Yes Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3215 No Yes 2 per 12 months RT LT Yes L3216 No Yes 2 per 12 months RT LT Yes L3217 No Yes 2 per 12 months RT LT Yes L3219 No Yes 2 per 12 months RT LT Yes L3221 No Yes 2 per 12 months RT LT Yes L3222 No Yes 2 per 12 months RT LT Yes L3224 No Yes 4 per 12 months RT LT Yes L3225 No Yes 4 per 12 months RT LT Yes L3230 No Yes 4 per 12 months RT LT Yes L3250 No Yes 4 per 12 months RT LT Yes L3251 No Yes 4 per 12 months RT LT Yes L3252 No Yes 4 per 12 months RT LT Yes L3253 No Yes 4 per 12 months RT LT Yes L3524 No Yes 2 per 12 months RT LT Yes L3255 No Yes 2 per 12 months RT LT Yes L3257 No Yes 2 per 12 months RT LT Yes L3260 No Yes 4 per 12 months RT LT Yes L3265 No Yes 4 per 12 months RT LT Yes L3300 No Yes 4 per 12 months RT LT Yes L3310 No Yes 4 per 12 months RT LT Yes L3320 No Yes 4 per 12 months RT LT Yes L3332 No Yes 2 per 12 months RT LT Yes L3334 No Yes 4 per 12 months RT LT Yes L3350 No Yes 4 per 12 months RT LT Yes L3360 No Yes 4 per 12 months RT LT Yes L3370 No Yes 4 per 12 months RT LT Yes L3390 No Yes 4 per 12 months RT LT Yes L3400 No Yes 4 per 12 months RT LT Yes L3420 No Yes 4 per 12 months RT LT Yes L3450 No Yes 4 per 12 months RT LT No L3455 No Yes 4 per 12 months RT LT No L3460 No Sometimes 4 per 12 months RT LT No L3465 No Sometimes 4 per 12 months RT LT No L3470 No Sometimes 4 per 12 months RT LT No L3480 No Sometimes 4 per 12 months RT LT No L3485 No Sometimes 4 per 12 months RT LT No L3500 No Sometimes 4 per 12 months RT LT No L3510 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3540 No Sometimes 4 per 12 months RT LT No L3570 No Sometimes 4 per 12 months RT LT Yes L3580 No Sometimes 4 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3590 No Sometimes 4 per 12 months RT LT No L3595 No Sometimes 4 per 12 months RT LT No L3600 No Sometimes 2 per 12 months RT LT No L3610 No Sometimes 2 per 12 months RT LT No L3620 No Sometimes 2 per 12 months RT LT No L3630 No Sometimes 2 per 12 months RT LT No L3640 No Sometimes 2 per 12 months RT LT No L3649 No Sometimes 2 per 12 months RT LT No L3650 No Sometimes 2 per 12 months RT LT No L3651 No Sometimes 2 per 12 months RT LT No L3652 No Sometimes 1 per 12 months -- No L3600 No Sometimes 2 per 12 months RT LT No L3670 No Sometimes 2 per 12 months -- No L3675 No Sometimes 2 per 12 months -- No L3700 No Sometimes 2 per 12 months RT LT No L3701 No Sometimes 2 per 12 months RT LT No L3710 No Sometimes 2 per 12 months RT LT No L3720 No Sometimes 2 per 12 months RT LT No L3730 No Sometimes 2 per 12 months RT LT No L3740 No Sometimes 2 per 12 months RT LT No L3760 No Sometimes 2 per 12 months RT LT No L3762 No Sometimes 2 per 12 months RT LT No L3800 No Sometimes 2 per 12 months RT LT No L3805 No Sometimes 2 per 12 months RT LT No L3807 No Sometimes 2 per 12 months RT LT No L3810 No Sometimes 2 per 12 months RT LT No L3815 No Sometimes 2 per 12 months RT LT No L3820 No Sometimes 2 per 12 months RT LT No L3825 No Sometimes 2 per 12 months RT LT No L3830 No Sometimes 2 per 12 months RT LT No L3835 No Sometimes 2 per 12 months RT LT No L3840 No Sometimes 2 per 12 months RT LT No L3845 No Sometimes 2 per 12 months RT LT No L3850 No Sometimes 2 per 12 months RT LT No L3855 No Sometimes 2 per 12 months RT LT No L3860 No Sometimes 2 per 12 months RT LT No L3890 No Sometimes 2 per 12 months RT LT No L3900 No Sometimes 2 per 12 months RT LT No L3901 No Sometimes 2 per 12 months RT LT No L3902 No Sometimes 2 per 12 months RT LT No L3904 No Sometimes 2 per 12 months RT LT No L3906 No Sometimes 2 per 12 months RT LT No L3907 No Sometimes 2 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3908 No Sometimes 2 per 12 months RT LT No L3909 No Sometimes 2 per 12 months RT LT No L3910 No Sometimes 2 per 12 months RT LT No L3911 No Sometimes 2 per 12 months RT LT No L3912 No Sometimes 2 per 12 months RT LT No L3914 No Sometimes 2 per 12 months RT LT No L3916 No Sometimes 2 per 12 months RT LT No L3920 No Sometimes 2 per 12 months RT LT No L3922 No Sometimes 2 per 12 months RT LT No L3923 No Sometimes 2 per 12 months RT LT No L3924 No Sometimes 2 per 12 months RT LT No L3926 No Sometimes 2 per 12 months RT LT No L3928 No Sometimes 2 per 12 months RT LT No L3930 No Sometimes 2 per 12 months RT LT No L3932 No Sometimes 2 per 12 months RT LT No L3934 No Sometimes 2 per 12 months RT LT No L3936 No Sometimes 2 per 12 months RT LT No L3938 No Sometimes 2 per 12 months RT LT No L3940 No Sometimes 2 per 12 months RT LT No L3942 No Sometimes 2 per 12 months RT LT No L3944 No Sometimes 2 per 12 months RT LT No L3946 No Sometimes 2 per 12 months RT LT No L3948 No Sometimes 2 per 12 months RT LT No L3950 No Sometimes 2 per 12 months RT LT No L3952 No Sometimes 2 per 12 months RT LT No L3954 No Sometimes 2 per 12 months RT LT No L3956 No Sometimes 2 per 12 months RT LT No L3960 No Sometimes 2 per 12 months RT LT No L3962 No Sometimes 2 per 12 months RT LT No L3963 No Sometimes 2 per 12 months RT LT No L3964 No Sometimes 2 per 12 months RT LT No L3965 No Sometimes 2 per 12 months RT LT No L3966 No Sometimes 2 per 12 months RT LT No L3968 No Sometimes 2 per 12 months RT LT No L3969 No Sometimes 2 per 12 months RT LT No L3970 No Sometimes 2 per 12 months RT LT No L3972 No Sometimes 2 per 12 months RT LT No L3974 No Sometimes 2 per 12 months RT LT No L3980 No Sometimes 2 per 12 months RT LT No L3982 No Sometimes 2 per 12 months RT LT No L3984 No Sometimes 2 per 12 months RT LT No L3985 No Sometimes 2 per 12 months RT LT No L3986 No Sometimes 2 per 12 months RT LT No Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3995 No Sometimes 2 per 12 months RT LT No L3999 No Sometimes -- RT LT No L4000 No Sometimes 1 per 12 months -- No L4010 No Sometimes 1 per 12 months RT LT No L4020 No Sometimes 2 per 12 months RT LT No L4030 No Sometimes 2 per 12 months RT LT No L4040 No Sometimes 2 per 12 months RT LT No L4045 No Sometimes 2 per 12 months RT LT No L4050 No Sometimes 2 per 12 months RT LT No L4055 No Sometimes 2 per 12 months RT LT No L4060 No Sometimes 2 per 12 months RT LT No L4070 No Sometimes 4 per 12 months RT LT No L4080 No Sometimes 2 per 12 months RT LT No L4090 No Sometimes 2 per 12 months RT LT No L4100 No Sometimes 2 per 12 months RT LT No L4110 No Sometimes 2 per 12 months RT LT No L4130 No Sometimes 2 per 12 months RT LT No L4205 No Sometimes -- -- No L4210 No Sometimes -- -- No L4350 No Sometimes 2 per 12 months RT LT No L4360 No Sometimes 2 per 12 months RT LT No L4370 No Sometimes 2 per 12 months RT LT No L4380 No Sometimes 2 per 12 months RT LT No L4386 No Sometimes 2 per 12 months RT LT No L4392 No Sometimes 2 per 12 months RT LT No L4394 No Sometimes 2 per 12 months RT LT No L4396 No Sometimes 2 per 12 months RT LT No L4398 No Sometimes 2 per 12 months RT LT No T2003 No Sometimes -- -- No