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

Evicore covers static upper‑extremity orthoses (shoulder through finger) for the listed conditions (recent injury/surgery, arthritis, peripheral nerve compression, epicondylitis, fracture, tenosynovitis/tendinitis, paresis/weakness, contracture, spasticity) and is limited to the HCPCS codes in the policy; dynamic orthoses and non‑upper‑extremity devices are excluded. Coverage requires documentation of one of the listed conditions and that therapy/exercise is included in the plan of care, with additional documentation for contractures (no/minimal progress with OT/PT and functional impairment) and for spasticity (functional impairment and botulinum toxin used or discussed) plus clinical notes supporting medical necessity and choice of a static orthosis.

"Policy is limited to upper extremity orthoses (shoulder through finger) — orthoses for other body regions are outside the scope of this document."