L3904 — Wrist hand finger orthosis, external powered, electric, custom fabricated
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit.
- Equipment expected to make a meaningful contribution to treatment of the patient’s illness or injury or to improvement of a malformed body member.
- Coverage only when education regarding use of the device has been provided with demonstrated understanding and a trial of the requested device has been completed with demonstrated ability to use it safely and effectively.
- DME is covered when it is medically necessary and reasonable to treat the member’s condition.
- DME is covered when it provides therapeutic benefit proportional to its expense and is not duplicative of equipment already available to the member.
- Burn garments are considered medically necessary when furnished with associated physical and/or occupational therapy and when the policy's specified criteria are met.
1 Active Policy
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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