Rehabilitation and Prosthetic Services

Eligibility of Clothing Allowance based on Orthotic/Prosthetic devices

Flowchart for helping to determine eligibility of clothing allowance based on Orthotic/Prosthetic devices

 

Recommended HCPC’s eligible for Clothing Allowance

Updates from previous version include:

• Added codes: K1007; L2006
• Added clarification comments to the KAFO, HKAFO, and Prosthetics sections.

The following list represents HCPC codes that may indicate entitlement for clothing allowance benefit. The codes in this list are not intended to give an automatic approval but are to be used as a guide as to when an item should be considered. Velcro strapping or different sized clothing are not factors to be considered with clothing allowance.
Should a veteran provide evidence of clothing damage, caused by a particular orthotic device which not represented by any of the codes contained in this list (and not due to factors deemed ineligible, such as those mentioned above) then strong consideration should be given to authorizing clothing allowance.
Codes for cervical orthoses are not included as these devices are usually intended for emergency/short term use.
Lumbosacral orthoses, in general, are excluded as they are usually off the shelf with adequate coverage on their rigid panels. There are few, if any, moving parts. Wrist hand finger orthoses are not typically damaging to clothing, so the codes for these devices were excluded from the list.

Spinal Orthoses

Thoraco Lumbo Sacral Orthoses (TLSO)

L0458 - TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment.

L0460 - TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes  fitting and adjustment.

L0462 - TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment.

L0464 - 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 the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment.

L0466 - TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures, and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.

L0468 - TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures, and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral discs, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0470 - TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures, and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral discs, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment.

L0472 - TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment.

L0480 - TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0482 - 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

L0484 - 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

L0486 - 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

L0488 - 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, prefabricated, includes fitting and adjustment

L0490 - TLSO, sagittal-coronal control, one-piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

L0491 - TLSO, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0492 - TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

Cervical Thoraco Lumbo Sacral Orthoses (CTLSO)

L0700 - CTLSO, anterior-posterior-lateral control, molded to patient model, (Minerva type

L0710 - CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material, (Minerva type)

L0810 - Halo procedure, cervical halo incorporated into jacket vest

L0820 - Halo procedure, cervical halo incorporated into plaster body jacket

L0830 - Halo procedure, cervical halo incorporated into Milwaukee type orthosis

Scoliosis Orthosis

L1000 - CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model

L1200 - TLSO, inclusive of furnishing initial orthosis only

L1300 - Other scoliosis procedure, body jacket molded to patient model

Lower Limb Orthoses

Hip Orthoses (HO)

L1845 - HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated

L1686 - HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment L1690 - Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment.

Knee Orthoses (KO)

L1820 - KO, elastic with joint(s), includes soft interface material, prefabricated, off- the-shelf

L1831 - KO, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832 - 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

L1833 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf

L1834 - KO, without knee joint, rigid, custom fabricated

L1836 - KO, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf

L1840 - KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843 - KO, single 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

L1844 - KO, single 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

L1845 - 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

L1846 - 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, custom fabricated

L1847 - KO, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1848 - Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf

Ankle Foot Orthoses (AFO)

L1900 - AFO, spring wire, dorsiflexion assist, calf band, custom fabricated

L1910 - AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment

L1920 - AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

L1930 - AFO, plastic or other material, prefabricated, includes fitting and adjustment

L1932 - AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment

L1940 - AFO, plastic or other material, custom fabricated

L1945 - AFO, plastic, rigid anterior tibial section (floor reaction), custom fabricated

L1950 - AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated

L1951 - AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment

L1960 - AFO, posterior solid ankle, plastic, custom fabricated

L1970 - AFO, plastic with ankle joint, custom fabricated

L1971 - AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment

L1980 - AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff

(single bar “BK” orthosis), custom fabricated

L1990 - AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff

(double bar “BK” orthosis), custom fabricated

Knee Ankle Foot Orthoses (KAFO)

(Generally speaking, all KAFO designs, even fits L-code is not listed below, should be considered for Clothing Allowance approvals.

Note – CMS adds/deletes HCPC codes on an annual basis, therefore, over time there may be new KAFO codes that have not yet been added to this list.)

L2000 - KAFO, single upright, free knee, free ankle, solid stirrup, thigh, and calf

band/cuffs (single bar “AK” orthosis), custom fabricated

L2005 - KAFO, any material, single or double upright, stance control, automatic lock, and swing phase release, any type activation, includes ankle joint, any type, custom fabricated

L2006 – KAFO, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated

L2010 - KAFO, single upright, free ankle, solid stirrup, thigh, and calf band/cuffs (single bar “AK” orthosis), without knee joint, custom fabricated

L2020 - KAFO, double upright, free ankle, solid stirrup, thigh, and calf band/cuffs

(double bar “AK” orthosis), custom fabricated

L2030 - KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs

(double bar “AK” orthosis), without knee joint, custom fabricated

L2034    - KAFO, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated

L2036 - KAFO, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom

fabricated

L2037 - KAFO, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated

L2038 - KAFO, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated

Hip Knee Ankle Foot Orthoses (HKAFO)

(Generally speaking, all HKAFO designs, even fits L-code is not listed below, should be considered for Clothing Allowance approvals.

Note – CMS adds/deletes HCPC codes on an annual basis, therefore, over time there may be new HKAFO codes that have not yet been added to this list.)

L2040 - HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated

L2050 - HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated

L2060 - HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated

L2070 - HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

L2080 - HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

L2090 - HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

K1007 – Bilateral HKAFO, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors

Upper Limb Orthoses

Shoulder Orthoses (SO)

L3674 - SO, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion

Elbow Orthoses (EO/EWHO/EWHFO)

L3720 - EO, double upright with forearm/arm cuffs, free motion, custom fabricated

L3730 - EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

L3740 - EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

L3760 - EO, with adjustable position locking joint(s), prefabricated, includes fitting and adjustments, any type

L3762 - EO, rigid, without joints, includes soft interface material, prefabricated, off- the-shelf

L3763 - EWHO, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764 - EWHO, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3765 - EWHFO, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3766 - EWHFO, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Shoulder Elbow Wrist Hand Orthoses (SEWHO)

L3960 - SEWHO, abduction positioning, airplane design, prefabricated, includes fitting and adjustment

L3961 - SEWHO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962 - SEWHO, abduction positioning, Erbs palsy design, prefabricated, includes fitting and adjustment

L3967 - SEWHO, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3971 - SEWHO, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3973 - SEWHO, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3975 - SEWHFO, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3976 - SEWHFO, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom

fabricated, includes fitting and adjustment

L3977 - SEWHFO, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3978 - SEWHFO, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Prosthetics

Lower Limb Prosthetics:

Any Veteran with a service-connected amputation proximal to the level of toe amputations, and wears a prosthesis, should be eligible for clothing allowance for the amputated limb.

Clothing Allowance entitlement, relating to the patient’s functional status with using a prosthesis, should be reviewed, at minimum, every 5 years.

Upper limb Prosthetics:

Any Veteran with a service-connected amputation proximal to the level of finger amputations, and wears a prosthesis, should be eligible for clothing allowance for the amputated limb.

Clothing Allowance entitlement, relating to the patient’s functional status with using a prosthesis should be reviewed, at minimum, every 5 year