Static Upper Extremity Orthoses - DME.MU.113.A

Prefabricated static upper‑extremity orthoses (shoulder through finger, including volar wrist splints for carpal tunnel) are medically necessary for limited joint ROM or stiffness from injury/surgery, peripheral nerve compression, arthritis, tendonitis, muscle weakness, contracture, or spasticity, while prophylactic bracing and duplicate/same‑case orthoses are not covered. Custom‑fabricated orthoses are covered only if a prefabricated device cannot be fitted and the condition is expected to be permanent/long‑standing (>6 months) with a deformity necessitating custom fit; replacements require a recent provider visit with a documented care plan plus evidence of growth/change, loss/theft, or irreparable damage/out‑of‑warranty, and proper diagnostic/conservative‑treatment documentation must be provided.

"Static upper extremity orthoses (braces) are addressed by this guideline, including: shoulder, shoulder-elbow, shoulder-elbow-wrist-hand, elbow, elbow-wrist-hand, elbow-wrist-hand-finger, wrist-han..."