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CATALOG2 0 1 7
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
ORTHOPEDIC BRACING PROGRAM
DESIGNED FOR NURSING HOMES & REHAB FACILITIES
If the patient is being discharged from their Part A stay, the Delivery Ticket must be signed within 2 days of discharge.
If the resident is not nearing their Part A discharge, please have purchaser provide you with the item and we will supply the same upon discharge.
Facility sends PME:1. Completed Brace Request Form2. Patient Facesheet 3. Clinical/Rehab Notes
FACILITY
Facility returns all completed and signed forms to PME for final review.****If resident is unable to sign, please have the Admin/DON/DOR/Direct Patient Care RN or Direct Patient Care Therapist sign, add title and reason why resident is unable to sign.
FACILITY
PME does a complete insurance verification and eligibility check, and confirms the appropriate HCPCS code for the order. You will then receive a script for the doctor to complete as well as a Billing Authorization Form to be signed by the resident or other qualified signee.** If we find the brace is not covered, please forward your request to the designated purchaser for your facility.
STEP 2 PME
PME confirms the documentation is correct and has brace shipped directly to the facility.
PME
GUARANTEED TO FIT • QUICK DELIVERY • OFF THE SHELF BRACING/SPLINTINGNO COST TO THE PATIENT • NO COST TO THE FACILITY
STEP 1
STEP 3 STEP 4
TABLE OFCONTENTS
Hip
Knee
Spine/Back
Elbow/Shoulder
Wrist/Hand
Cervical Collar
Ankle/Foot
Cam Walker/Night Splint
4
6
7
8
10
11
12
13
14
23
Size Charts/Coverage Criteria
Brace Request Form
4
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 14 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Non-ROM Wrap Hinged Knee Brace Non-ROM Knee (Wrap/Sleeve) Brace
Recommend HCPCS Code L1820 Recommend HCPCS Code L1820
• Wrap design for customized fit• Lightweight, stretch material• Padding around hinges for comfort• Removable and easy to set hinges
• Cooltech fabric helps keep skin dry• Brace retains original elasticity, reducing
popliteal bunching• Easy to adjust straps and hinges for support
where needed• Sleeve model includes removable patella
support
KNEE
0204
Locking Knee Contracture Orthosis Flex Knee ROM Contracture Brace
Recommend HCPCS Code L1831 Recommend HCPCS Code L1831
• Easy to use pull ring and lock mechanism• Six possible positions• No additional tools necessary• Removable, machine washable covers
• X strap for complete knee range of motion
• Gel knee pad included for added comfort
• Easy to set ROM hinge• Flex design to accommodate
involuntary muscle contractions
0202 0203
0205
ROM Knee Wrap/Sleeve Brace ROM Hinged Knee Brace
Recommend HCPCS Code L1832/L1833
• Cooltech fabric helps keep skin dry• Brace retains original elasticity, reducing
popliteal bunching• Easy to adjust straps for support where
needed• Sleeve model includes removable patella
support
• Wrap design for customized fit• Lightweight, stretch material• Padding around hinges for comfort• Removable and easy to set hinges
0200 0201
Recommend HCPCS Code L1832/L1833for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
5
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 15 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
OA Knee Brace With ROM
• Three point pressure system to redistribute weight and alleviate pain
• Customizable, lightweight aluminum semi-rigid distal and proximal straps
• Unzip brace to easily access adjustable flexion/extension support
• Buttress contains two thickness options as well as a patellar support
0207
Recommend HCPCS Code L1843/K0901
for sizing, see size index at the back of the catalog
ACL ROM Knee Brace
OA Wraparound Knee Brace
Unloader OA Knee Brace
Exoform® Knee Immobilizer Quick Knee Immobilizer
• Easy adjust hinge• Lightweight frame• Support and stability during
healing• Allows for mobility
• Soft comfortable Lycra material• Non-slip straps for ease of use• Dot coded closures simplify donning
process• One strap closure for immediate
compression
• Design with quick release snaps for easy on-off
• Three point knee pressure reduction system
• Varus and Valgus adjustment for perfect alignment
• Easily adjust hinge setting
• Easy to fit with “slide to size” straps• Dual cuffs and popliteal supports for exact
immobilization• Sleeve under brace for patient warmth• Cool version available upon request• Durable, comfortable and latex free
• Velcro straps provide superior compression• Adjustable medial and lateral stays• Posterior stays contoured for extra support• Universal size fits most
KNEE
0206
0210
0208 0209
0211
Recommend HCPCS Code L1843/K0901
Recommend HCPCS Code L1843/K0901
Recommend HCPCS Code L1830 Recommend HCPCS Code L1830
Recommend HCPCS Code L1845/K0902
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
Universal Sizing
6
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 16 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Miami Lumbosacral Orthosis (LSO) with Rigid Removable Panel
• Designed with anterior/posterior panels• Optional lateral supports• Breathable fabric keeps patients cool• Easy adjust
SPINE/BACK
TLSO Back Brace Figure 8 Clavicle SplintScoliosis Bracing System
• Easy to use and adjust for individual patient needs
• Padded sensil and pectoral pads for comfort
• Provide immobilization where needed all along the spine
• Variety of panels available to create customized TLSO
• Clavicle Splint• Easy to adjust for patient• Comfortable felt pad• Prong buckle closure
prevents strap slippage• Holds shoulders back to
aid in healing
• Universal sizing• Pulley system for easy adjustment• Removable lateral iliac panel• Multiple configuration options
0212
Transformer Back Brace/LSO Elastic Deluxe LSO with Rigid Removable Panel
• Posterior and anterior support through rigid panels
• Easy on and off• Simple to adjust with double pull system• Breathable mesh fabric covered belt• Removable 14” back panel
• Lightweight low profile design• Removable posterior panel for
exact comfort• Elastic compression pulls for
support where needed• Breathable mesh fabric
0213 0214
Recommend HCPCS Code L0631/L0648
Recommend HCPCS Code L0631/L0648 Recommend HCPCS Code L0631/L0648
Recommend HCPCS Code L0462 Recommend HCPCS Code L1005 Recommend HCPCS Code L3660
0215 0216 0217
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
one size fits all one size fits all
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
7
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 17 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
one size fits all one size fits all
ELBOW/SHOULDER
Hinge ROM Elbow Brace
Humeral Fracture Shoulder Brace
Shoulder/Arm Abduction System
Shoulder Immobilizer With Waist Strap
• Padded for comfort• Telescopic adjustments for length• Adjustable straps for perfect fit• Pin type hinge for exact ROM
• Two part padded clamshell design for ultimate compression
• Deltoid cap extension to provide extra control• Comes with two double thickness cotton
stockinettes• Can be used for either arm
• Universal sizing due to telescoping arms• Removable wedge for shoulder positioning• Lightweight and easy to wear• Strapping system allows for use in either arm
• Breathable canvas fabric for patient comfort• Easily immobilize shoulder with simple
strapping design• Prevent wrist drop with thumb loop
Contracture Locking Elbow Orthosis
• Assists with elbow extension• Easy to use pull ring and lock mechanism• Six possible positions• No additional tools necessary
• Length and cuffs easily adjust for custom fit
• Adjust flexion/extension of elbow without removing stays
• Brace can be set for pronation or supination
• Washable, removable terry cloth cover
• Adjustable and trimmable straps allow for custom placement
• Padded condyle protection• Easy to apply, universal sizing• Can be used for Contracture
Management
Elbow/Wrist/Hand Combination Locking Orthosis
ROM Padded Elbow Orthosis
0218
0219 0220
0221 0222
0223 0224
Recommend HCPCS Code L3760
Recommend HCPCS Code L3760 and L3809/3807 Recommend HCPCS Code L3760
Recommend HCPCS Code L3980 Recommend HCPCS Code L3660
Recommend HCPCS Code L3960Recommend HCPCS Code L3760
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalogfor sizing, see size index at the back of the catalog
8
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 18 AND 19 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
WRIST/HAND
Fabric Lace Wrist Splint
• Composed of two different fabrics for comfort and ease of use• Unique design allows for multiple closing options• Easily adjust removable aluminum stays• Patented M Brace technology
• Palm area contoured to assist full finger function• Thumb and Palmer stays removable and adjustable for
exact support• Breathable fabric for comfort• Velcro straps for perfect fit
Thumb Spica Wrist Brace
Recommend HCPCS Code L3908
0227 0228
Recommend HCPCS CodeL3809/3807
Choose from an array of hand/wrist splints designed for the care and comfort of patients with contractures. All splints are easy to fit and adjust as necessary. Soft and durable, comfortable enough to endure any wearing schedule.
Air Graduate WHFO Dorsal Resting Hand Functional RestingGrip Resting Hand (Thumb Ease)finger separator optional
Palmar Resting Hand
Hand/ Wrist Contracture Splints0226
Recommend HCPCS Code L3809/3807
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
• Supports finger, hand and wrist• Easily adjust internal aluminum stay• For functional/resting use
Air Soft Resting Hand Splint0225
Recommend HCPCS Code L3809/3807
for sizing, see size index at the back of the catalog
9
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 19 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
WRIST/HAND
Carpal Tunnel/Arthritis GlovePremium Wrist Splint
• Thermoskin glove allows for all day comfort
• Compression and heat therapy combined with rigid metal splint for control
• A perfect combination of a wrist splint with arthritis glove
• Velcro locking strap for perfect fit
• Lycra lined splint for moisture wicking comfort
• Removable palmer stay for exceptional support
• Velcro closure for perfect fit
Air Hand/Wrist Contracture Splint
• Provides support to fingers, hand and wrist
• Air bladders with contoured bulb for thumb abduction
• Fleece liner for comfort and ease of pressure points
• Assists patients with strong flexion synergy of wrist/hand
• Flexible frame and adjustable wrist hinge for perfect fit
• Finger separators included to prevent locking.
• Universal sizing, fits left and right
Deluxe Wrist Hand Contracture Splint
0229 0230
0231 0232
Recommend HCPCS Code L3809/3807Recommend HCPCS Code L3915/L3916
Recommend HCPCS Code L3908 Recommend HCPCS Code L3908
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
one size fits allone size fits all
10
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 20 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Recommend HCPCS Code L1686 Recommend HCPCS Code L1652
Recommend HCPCS Code L1690
OA Unloader Hip Brace
• Comfortable Lycra, discreet under clothes
• Unique pulley system delivers compression where needed
• Control external hip rotation with Rotation Control Strap
• Three strap system for rapid post-op application
• Range of Motion set in 15 degree increments and locking options
• Malleable aluminum frame with breathable foam cover
• Soft and comfortable therapy for hip and knee contractures
• Three abduction settings• Flexible cuffs with pressure reduction foam
for perfect fit• Orthowick fabric helps maintain skin
integrity
Post-Op Hip Brace Hip Knee Orthosis
0233
0234 0235
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
HIP
one size fits all
11
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 20 AND 21 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Posterior Carbon Fiber AFO Dynamic Carbon Fiber AFO
Foot Drop SplintRebound Hinged Ankle Brace
Legend Ankle Brace
• Helps reduce plantar flexion movement• Lightweight carbon fiber construction for high
energy return• Padded straps for comfort and ease of fit• Suggested weight up to 285 lbs
• Lightweight padded carbon fiber construction• Full length toe lever absorbs shock and provides
support to ankle and foot• Designed for maximum support and minimal
visibility• Suggested weight up to 265 lbs
• Lightweight polypropylene material• Easy to trim flexible, thin foot part• Open heel section for comfort• Thickness varies throughout, providing support
where needed
• Provides support during transition from walker, boot or cast
• Velcro closure for ease of fit• Optional stability strap• Can be configured in multiple ways for
optimal control
• Adjustable Velcro closures for perfect fit
• Full flexion ankle joints for ease of or restriction of motion
• Orthotic foot plate supports foot and ankle
• Perfect for immediate use
ANKLE/FOOT
0236 0237
Recommend HCPCS Code L1951 Recommend HCPCS Code L1932
Recommend HCPCS Code L1906
02400239 0241
Recommend HCPCS Code L1906 Recommend HCPCS Code L1930
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
Accord Hinged Ankle Brace
• Hard shell foot plate and adjustable calf cuff for support
• Soft inner liner for comfort• Quick lace system for ease of use• Optional posterior panel• Detachable posterior calf panel included
Recommend HCPCS Code L1971
0238
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalogfor sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
12
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 21 & 22 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
CAM WALKER/NIGHT SPLINT
Posterior Night Splint
Dorsal Night Splint Ambulating Contracture Podus AFO*Must have another diagnosis other than wound diagnosis*
Recommend HCPCS Code L4396/L4397
Recommend HCPCS Code L4396/L4397 Recommend HCPCS Code L4396/L4397
• Gentle stretch of plantar fascia through strapping configuration
• Lightweight and padded construction for comfort while sleeping
• Toe wedge included for additional stretch if needed
• Fits either left or right foot
• Soft, flexible brace, almost like wearing a sock• Easily fasten and adjust with Velcro closures• Gentle stretch provided through simple dorsi-
flexion strap• Fits either left or right foot
• Transitional brace comfortable in bed or while ambulating
• “Click Step” rocker bottom assists initial gait training
• Semi rigid insert can be heat molded to accommodate plantar flexion
• Optional fleece liner
Stabilizer Range of Motion Walker Air Walker (High or Low)
• Air bladders for customized compression
• Toe guard for added protection• Velcro straps and padded insole
for comfort and fit• Fits either left or right foot
• Rocker bottom for smooth walking• Easy to set ROM joint• Velcro straps for perfect fit• Fits either left or right foot
0244
0245 0246
02430242
Recommend HCPCS Code L2112 Recommend HCPCS Code L4360/L4361
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
13
BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 22 BEFORE MAKING SELECTION.
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Elite Cervical Orthosis Cervical Collar
• Aluminum frame for lightweight support• Vented for easy air flow • MRI compatable• Designed for full linear adjustment
• Lightweight preformed foam with plastic reinforcement for comfort and stability
• Two piece collar easily adjusts• Secured with Velcro closures• Large trachea opening
0247 0248
Recommend HCPCS Code L0180 Recommend HCPCS Code L0172
for sizing, see size index at the back of the catalog for sizing, see size index at the back of the catalog
CERVICAL COLLAR
14
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Size Knee Circumference*
Small 12.5” - 14.5”
Medium 14” - 16”
Large 15.5” - 18”
X Large 17.5” - 20”
Size Knee Circumference*
2X Large 19.5” - 22”
3X Large 21.5” - 24”
4X Large 25” - 28”
5X Large 29” - 32”
Size CalfCircumference
Thigh Circumference
Adult 16”-20” 19”-23
Size ThighCircumference
Small 11”-15”
Medium 15”-19”
Large 19”-21”
Size CalfCircumference
Small 7”-10”
Medium 10” - 13”
Large 13” - 16”
Size Circumference
X Small 11.5” - 13.75”
Small 13.75” - 16”
Medium 16” - 18”
Large 18” - 20.5”
Size Knee Circumference*
Small 12.5” - 14.5”
Medium 14” - 16”Large 15.5” - 18”
Size Circumference
X Large 20.5” - 22.5”
2X Large 22.5” - 24.75”
3X Large 24.75” - 28.5”
4X Large 28.8” - 32”
Size Knee Circumference*
X Large 17.5” - 20”
2X Large 19.5” - 22”3X Large 21.5” - 24”
0204-Non-ROM Wrap Hinged Knee Brace
0202-Locking Knee Contracture Orthosis
0203-Flex Knee ROM Contracture Brace
0205-Non-ROM Knee (Wrap/Sleeve) Brace
0200-ROM Knee Wrap/Sleeve Brace
0201-ROM Hinged Knee Brace
Size Circumference*
X Small 11.5” - 13.75”
Small 13.75” - 16”
Medium 16” - 18”
Large 18” - 20.5”
Size Circumference*
X Large 20.5” - 22.5”
2X Large 22.5” - 24.75”
3X Large 24.75” - 28.5”
4X Large 28.8” - 32”
Recommend HCPCS Code L1831
Recommend HCPCS Code L1831
Recommend HCPCS Code L1832/L1833
Recommend HCPCS Code L1832/L1833
Recommend HCPCS Code L1820
Recommend HCPCS Code L1820
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
UNDERLYING CONDITIONS: Contracture of knee OtherCOVERAGE CRITERIA: Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees
UNDERLYING CONDITIONS: Contracture of knee OtherCOVERAGE CRITERIA: Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees
UNDERLYING CONDITIONS: Osteoarthritis Congenital deformity of knee joint Rheumatoid Arthritis Chronic instability of knee OtherCOVERAGE CRITERIA: Ambulatory patient w/ weakness or deformity of knee requiring stabilization
UNDERLYING CONDITIONS: Osteoarthritis Congenital deformity of knee joint Rheumatoid Arthritis Chronic instability of knee OtherCOVERAGE CRITERIA: Ambulatory patient w/ weakness or deformity of knee requiring stabilization
*Circumferential measurement 6” above mid-patella
* Measure around center of knee with leg extended
* Measure around center of knee with leg extended
* Circumferential measurement 6” above mid-patella
KN
EE
15
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
Size
Universal Sizing Left Medial
Universal Sizing Right Medial
Universal Sizing Left Lateral
Universal Sizing Right Lateral
Size
Universal Sizing
Size Left Medial or Right Lateral
Small 13” - 16”
Medium 16” - 19.5”
Large 19.5” - 22.5”
X Large 22.5” - 25.5”
2X Large 25.5” - 29.5”
Size Right Medial or Left Lateral
Small 13” - 16”
Medium 16” - 19.5”
Large 19.5” - 22.5”
X Large 22.5” - 25.5”
2X Large 25.5” - 29.5”
Size Thigh Circumference* Calf Circumference**
XSmall 14-16"(36-41cm) 11-12.5"(28-32cm)
Small 16-18"(41-46cm) 12.5-14"(32-36cm)
Medium 18-21"(46-53cm) 14-16"(36-41cm)
Large 21-23.5"(53-60cm) 16-18"(41-46cm)
XLarge 23.5-26.5"(60-67cm) 18-20"(46-51cm)
2XLarge 26.5-29.5"(67-75cm) 20-22"(51-56cm)
3XLarge 29.5-32"(75-81cm) 22-24"(56-61cm)
Size Length
Universal 12”
Universal 16”
Universal 20”
Universal 24”
0206-OA Wraparound Knee Brace
0211-Quick Knee Immobilizer
0207-OA Knee Brace With ROM
0208-Unloader OA Knee Brace
0209- ACL ROM Knee Brace
0210-Exoform®KneeImmobilizer
Recommend HCPCS Code L1843/K0901
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
Recommend HCPCS Code L1843/K0901
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
Recommend HCPCS Code L1830
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury Recent surgical procedure on knee
Recommend HCPCS Code L1830
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury Recent surgical procedure on knee
*Measure thigh circumference 6” above mid patella **Measure calf circumference taken 6” below mid-patellaPlease specify if brace is for Medial or Lateral Unloading
*Circumferential measurement 6” above mid-patella
Size Thigh Circumference*
Small Right or Left
15.5” - 18.5”
Medium Right or Left
18.5” - 21”
Large Right or Left
21” - 23.5”
Size Thigh Circumference*
X Large Right or Left
23.5” - 26.5”
2X Large Right or Left
26.5” - 29”
Recommend HCPCS Code L1843/K0901
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
Recommend HCPCS Code L1845/K0902
UNDERLYING CONDITIONS: Osteoarthritis Multiple Sclerosis Old bucket handle of medial meniscus Chondromalacia of Patella Pathologic fracture of femur/tibia/fibula Rheumatoid Arthritis
Congenital deformity of knee joint ACL tear OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Recent knee injury or Recent surgical procedure on knee Patient is ambulatory and has knee instability due to diagnosis
*Thigh circumference should be measured approximately 6” above knee
KN
EE
16
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Size Waist Circumference
XS 26”-30" (66-76cm)
S 30”-34" (76-86cm)
M 34”-38" (86-96cm)
L 38”-42" (96-106cm)
XL 42”-46” (106-116cm)
Size Waist Circumference
Sm-XL 26”-52”
Extender belt Up to 75”
14” Back Panel
Size
Universal Sizing
Size
Universal Sizing
Size Waist Circumference
X-Small 26”-32”
Small 32”-36”
Medium 36”-40”
Large 40”-44”
Size Waist Circumference
X Large 44”-48”
2X Large 48”-52”
3X Large 52”-58”
4X Large 58”-64”
Size Sizing
XSmall 20-24"
Small 24-30”
Medium 30-36"
Size Sizing
Large 36-42”
XLarge 42-48”
0212-Miami Lumbosacral Orthosis (LSO) with Rigid Removable Panel
0213-Transformer Back Brace/LSO
0214-Elastic Deluxe LSO with Rigid Removable Panel
0215-TLSO Back Brace
0216-ScoliosisBracingSystem
0217-Figure 8 Clavicle Splint
UNDERLYING CONDITIONS: Osteoarthritis Spinal Stenosis Intervertebral disc disorders Sprain of spine and/or pelvis Other
COVERAGE CRITERIA: (Patient must meet one of the following criteria) Reduce pain by restricting mobility of trunk Help heal injury to spine or related soft tissue Help heal post-surgery to spine or related soft tissue Supporting weak spinal muscles and/or deformed spine
Recommend HCPCS Code L0631/L0648
UNDERLYING CONDITIONS: Osteoarthritis Spinal Stenosis Intervertebral disc disorders Sprain of spine and/or pelvis Other
COVERAGE CRITERIA: (Patient must meet one of the following criteria) Reduce pain by restricting mobility of trunk Help heal injury to spine or related soft tissue Help heal post-surgery to spine or related soft tissue Supporting weak spinal muscles and/or deformed spine
Recommend HCPCS Code L0631/L0648
UNDERLYING CONDITIONS: Osteoarthritis Spinal Stenosis Intervertebral disc disorders Sprain of spine and/or pelvis OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Reduce pain by restricting mobility of trunk Help heal injury to spine or related soft tissue Help heal post-surgery to spine or related soft tissue Supporting weak spinal muscles and/or deformed spine
Recommend HCPCS Code L0631/L0648
UNDERLYING CONDITIONS: Osteoarthritis Spinal Stenosis Intervertebral disc disorders Sprain of spine and/or pelvis OtherCOVERAGE CRITERIA: (Patient must meet one of the following criteria) Reduce pain by restricting mobility of trunk Help heal injury to spine or related soft tissue Help heal post-surgery to spine or related soft tissue Supporting weak spinal muscles and/or deformed spine
Recommend HCPCS Code L0462
UNDERLYING CONDITIONS: Scoliosis OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve spinal function. (Not preventative.)
Recommend HCPCS Code L1005
UNDERLYING CONDITIONS: Fracture of clavicle OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)
Recommend HCPCS Code L3660
SP
INE
/BA
CK
*Measure the chest circumference at the sternum area
Size Waist Circumference
2XL 46”-50” (116-127cm)
3XL 50”-54” (127-137cm)
4XL 54”-58” (137-147cm)
5XL 58”-62” (147-157cm)
6XL 62”-66” (157-167cm)
17
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
Size
Universal Sizing
Size
Universal Sizing
Size Bicep Circumference
Adult 11”-15”
Size Bicep Circumference
Adult Small 9”-12”
Adult 11”-15”
Size Bicep Circumference
Standard Up to 6’ Tall
Long Taller Than 6’
Size Mid-Bicep Circumference
Small 8”-11”
Medium 11”-14”
Large 12”-15”
X Large 14”-17”
Size MeasurementsSmall 13.5” long/ 7.5” sling depth
Medium 15.5” long/ 8.25” sling depth
Large 18” long/ 8.75” sling depth
0218-Contracture Locking Elbow Orthosis
0219-Elbow/Wrist/Hand Combination Locking Orthosis
0220-ROM Padded Elbow Orthosis
0221-Hinge ROM Elbow Brace
0222-Shoulder/Arm Abduction System
0223-Humeral Fracture Shoulder Brace
0224-Shoulder Immobilizer With Waist Strap
UNDERLYING CONDITIONS: Contracture of Elbow Rheumatoid Arthritis Hemarthrosis of Elbow OtherCOVERAGE CRITERIA: Item for treatment of illness or injury or to improve elbow function. (Not preventative.)
Recommend HCPCS Code L3760
UNDERLYING CONDITIONS: Contracture of Elbow Rheumatoid Arthritis Hemarthrosis of Elbow OtherCOVERAGE CRITERIA: Item for treatment of illness or injury or to improve elbow function. (Not preventative.)
UNDERLYING CONDITIONS: Rheumatoid Arthritis Contractures Wrist/Hand
OtherCOVERAGE CRITERIA: Item for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3760 Recommend HCPCS Code L3809/L3807
UNDERLYING CONDITIONS: Contracture of Elbow Rheumatoid Arthritis Hemarthrosis of Elbow Other
COVERAGE CRITERIA: Item for treatment of illness or injury or to improve elbow function. (Not preventative.)
Recommend HCPCS Code L3760
UNDERLYING CONDITIONS: Fracture of shaft of humerus OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)
Recommend HCPCS Code L3980
UNDERLYING CONDITIONS: Fracture of clavicle OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)
Recommend HCPCS Code L3660
UNDERLYING CONDITIONS: Frozen Shoulder (Adhesive Capsulitis) Arthritis of Shoulder Other
COVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)
Recommend HCPCS Code L3960
UNDERLYING CONDITIONS: Contracture of Elbow Rheumatoid Arthritis Hemarthrosis of Elbow Other
COVERAGE CRITERIA: Item for treatment of illness or injury or to improve elbow function. (Not preventative.)
Recommend HCPCS Code L3760
ELB
OW
/SH
OU
LDE
R
18
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
Air Graduate WHFO
Size Width of MP Joints
Adult 3.5-4”
Resting Hand (Thumb Ease)
Size Width of MP Joint Length
Small 2.5”-3” 11.25”
Medium 3”-3.5” 12.25”
Large 3.5”-4” 13.25”
Palmer resting hand & dorsal resting hand
Size Width of MP Joint Length
Small 2.5”-3” 10”
Medium 3”-3.5” 11”
Large 3.5”-4” 12”
Functional resting & Grip
Size Width of MP Joint Length
Small 2.5”-3” 9”
Medium 3”-3.5” 10”
Large 3.5”-4” 11”
0226-Hand/ Wrist Contracture Splints
UNDERLYING CONDITIONS: Rheumatoid Arthritis Contractures wrist/hand OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3809/3807
WR
IST/
HA
ND
Size Wrist Circumference
X Small 4.5”-5.5”
Small 5.5”-6.5”
Medium 6.5”-7.5”
Large 7.5”-8.5”
X Large 8.5”+
0227-Thumb Spica Wrist Brace UNDERLYING CONDITIONS: Rheumatoid Arthritis Contractures wrist/hand
OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3809/3807
Size Measurement
Small 2¼” - 2¾”
Medium 27/8” - 3¼”
Large 33/8” - 3¾”
0225-Air Soft Resting Hand Splint
Recommend HCPCS Code L3809/3807
UNDERLYING CONDITIONS: Rheumatoid Arthritis Contractures wrist/hand Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
*Measure Circumference of MP Joints
19
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
Size
Universal Sizing
Size
Universal Sizing
0230-Air Hand/Wrist Contracture Splint
0229-Deluxe Wrist Hand Contracture Splint
UNDERLYING CONDITIONS: Carpal Tunnel Syndrome Rheumatoid Arthritis Contractures wrist/hand OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3915/L3916
UNDERLYING CONDITIONS: Rheumatoid Arthritis Contractures wrist/hand Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3809/3807
WR
IST/
HA
ND
Size Wrist Circumference
X Small 4.5”-5.5”
Small 5.5”-6.5”
Medium 6.5”-7.5”
Large 7.5”-8.5”
X Large 8.5”+
Size Left & Right
Wrist Circumference
X Small 6” – 6-3/4”
Small 7” – 7-3/4”
Medium 8” – 8-3/4”
Large 9-1/4” – 10-1/4”
X Large 10-3/4” – 11-1/2”
2X Large 11-3/4” +
0231-Premium Wrist Splint
0232-Carpal Tunnel/Arthritis Glove
UNDERLYING CONDITIONS: Carpal Tunnel Syndrome Wrist Instability Other COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3908
UNDERLYING CONDITIONS: Carpal Tunnel Syndrome Wrist Instability Other COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3908
Size Wrist Circumference
Regular 5”-7.8”
Extra 7.8”-10.6”
0228-Fabric Lace Wrist Splint UNDERLYING CONDITIONS: Carpal Tunnel Syndrome Wrist Instability
OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve wrist/hand function. (Not preventative.)
Recommend HCPCS Code L3908
20
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
0233-OA Unloader Hip Brace
0234-Post-Op Hip Brace
0235-Hip Knee Orthosis
Size Measurements
Small 31”-35”
Medium 35”-38”
Large 38”-41”
X Large 41”-45”
2X Large 45”-49”
Size Measurements
Regular 5’4” and taller
Short Less then 5’4”
Size Fit
Small Up to 17”
Regular 17.5” and up
UNDERLYING CONDITIONS: Post-op Hip replacement surgery Hip dislocation Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.)
Recommend HCPCS Code L1686
UNDERLYING CONDITIONS: Osteoarthritis Contractures of the Hip or Knee Hip Abduction Hip Scissoring Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of the hip/knee. (Not preventative.)
Recommend HCPCS Code L1652
UNDERLYING CONDITIONS: Hip Osteoarthritis OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.)
Recommend HCPCS Code L1690
0236-Posterior Carbon Fiber AFO
Size Shoe Size
Small Right and Left M 4.5- 7, W 6- 8.5
Medium Right and Left M 7- 8.5, W 8.5- 10
Large Right and Left M 8.5- 11.5, W 10- 13
X Large Right and Left M 11.5- 14, W 13- 15.5
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements Drop Foot OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L1951
* Circumferential measurement 4” above mid-patella
HIP
AN
KLE
/FO
OT
*Measure the hip circumference at the anterior superior iliac spine
0237-Dynamic Carbon Fiber AFO
Size Shoe Size Foot Size
XSmall M 3-5W 4-6.5
8”-9”
Small M 5.5-7.5W 7-9
9”-10”
Medium M 8-10.5W 9.5-12
10”-10.75”
Large M 11-14 11”-11.5”
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements Drop Foot OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L1932
21
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
0238-Accord Hinged Ankle Brace
0241-Foot Drop Splint
0239-Legend Ankle Brace
Size Shoe Size
Small Right and Left M up to 8, W up to 9
Medium Right and Left M 8.5- 12, W 9.5- 13
Large Right and Left M 12+, W 13.5+
Size Shoe Size
Small Right and Left M up to 8, W up to 9
Medium Right and Left M 8.5- 12, W 9.5- 13
Large Right and Left M 12+, W 13.5+
Size Splint Height
Medium 10.5”
Large 11.5”
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L1971
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L1906
Recommend HCPCS Code L1906
UNDERLYING CONDITIONS: Osteoarthritis Contractures of ankle and foot Other joint derangements OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L1930
AN
KLE
/FO
OT
0242-Stabilizer Range of Motion Walker
0243-Air Walker (High and Low)
Size Men Shoe Size Women Shoe Size
X Small Up to 3 1/2 Up to 4 1/2
Small 4-7 5-8 1/2
Medium 7 1/2-10 9-11
Large 10 1/2-12 11 1/2-13
X Large 12 1/2+ 13 1/2+
Size Men Shoe Size Women Shoe Size
X Small Up to 4 Up to 5 1/2
Small 4 1/2-7 6-8
Medium 7 1/2-10 8 1/2-11 1/2
Large 10 1/2-12 1/2 11 1/2-13 1/2
X Large 12 1/2+ 13 1/2+
UNDERLYING CONDITIONS: Moderate to Severe sprains Stable fracture Post op stabilization OtherCOVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L2112
UNDERLYING CONDITIONS: Sprain-Ankle, Foot Fracture-Ankle, Foot, Toes Other
COVERAGE CRITERIA: Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally
Recommend HCPCS Code L4360/L4361
CA
M W
ALK
ER
/NIG
HT
SP
LIN
T
0240-Rebound Hinged Ankle Brace
Size Shoe Size
Small Women’s shoe 7-1/2 to 9, Men’s 6 to 7-1/2
Medium Women’s shoe 9-1/2 to 13, Men’s 8-12
Large Men’s shoe 12-1/2 to 16
22
ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA
INDEX
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
0244-Posterior Night Splint
Size Men Shoe Size Women Shoe Size
Small 4-6 5-7
Medium 6-10 7-11
Large 10-13 11-14
0245-Dorsal Night Splint
Size Men Shoe Size Women Shoe Size
Small/Medium Up to 9 Up to 10
Large/X Large 91/2 + 101/2 +
0246-Ambulating Contracture Podus AFOMust have another diagnosis other than wound diagnosis
Size Length of Foot
Max Calf Circumference
Small Fleece/Smooth 6”-8” 15”
Medium Fleece/Smooth 8”-10” 17”
Large Fleece/Smooth 10”-11” 19”
X Large Fleece/Smooth 11”-12” 23”
0247-Elite Cervical Orthosis
Size Neck Circumference
Small 11”- 15”
Medium 15”- 20” UNDERLYING CONDITIONS: Whiplash Herniated discs Post-operative support Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of malformed body member. (Not preventative.)
Recommend HCPCS Code L0180
0248-Cervical Collar
Size Neck Circumference
Small 10”-13”
Medium 13”-16”
Large 16”-19”
X Large 19”-23”
UNDERLYING CONDITIONS: Whiplash Herniated discs Mid neck injuries Other
COVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of malformed body member. (Not preventative.)
Recommend HCPCS Code L0172
CA
M W
ALK
ER
/NIG
HT
SP
LIN
TC
ER
VIC
AL
CO
LLA
R
Recommend HCPCS Code L4396/L4397
UNDERLYING CONDITIONS: Contracture of Ankle Contracture of Foot Plantar Fascial Fibromatosis OtherCOVERAGE CRITERIA: (Patient must meet one of the 2 following criteria) Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees. AND Reasonable expectation of the ability to correct the contracture AND Contracture is interfering/expected to interfere significantly with functional abilities AND Splint is used as part of therapy program including active stretching of the involved muscles/tendonsOR Plantar Fasciitis
UNDERLYING CONDITIONS: Contracture of Ankle Contracture of Foot Plantar Fascial Fibromatosis OtherCOVERAGE CRITERIA: (Patient must meet one of the 2 following criteria) Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees. AND Reasonable expectation of the ability to correct the contracture AND Contracture is interfering/expected to interfere significantly with functional abilities AND Splint is used as part of therapy program including active stretching of the involved muscles/tendonsOR
Plantar Fasciitis
Recommend HCPCS Code L4396/L4397
Recommend HCPCS Code L4396/L4397
UNDERLYING CONDITIONS: Contracture of Ankle Contracture of Foot Plantar Fascial Fibromatosis OtherCOVERAGE CRITERIA: (Patient must meet one of the 2 following criteria) Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees. AND Reasonable expectation of the ability to correct the contracture AND Contracture is interfering/expected to interfere significantly with functional abilities AND Splint is used as part of therapy program including active stretching of the involved muscles/tendonsOR Plantar Fasciitis
BRACE REQUEST FORMSUBMIT WITH RESIDENT FACESHEET
Date: / /
Facility Name:
Requester Name:
Patient Name:
Item/Item #: QTY: Size: If applicable please specify “R”, “L”, or “Both”
Catalog Used: PME Catalog Other:
Diagnosis Code(s):
Rehab Payer Source: Med A Med B Medicaid Other
Stay: Long Term Short Term
Date of Med A DC: / / Date of DC to Home: / /
ProMedical East | P:877-303-8050 | F:732-348-1150 | [email protected]
P: 877-303-8050
F: 732-348-1150
A: 1995 Rutgers University Blvd
Lakewood, NJ 08701