Custom Fabricated - JA DME

A custom fabricated orthosis is one which is individually made for a specific beneficiary (no other beneficiary would be able to use this orthosis) starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc. It requires more than trimming, bending, or making other modifications to a prefabricated item.

To support medical necessity of custom fabricated rather than a prefabricated orthosis, include detailed documentation in the treating physician's records. This information will be corroborated by a functional evaluation in the orthotist or prosthetist's records and must be available upon request.

Billing Not Otherwise Classified (NOC) Custom Fabricated Codes When No Specific HCPCS Code Exists

Bill with appropriate miscellaneous code

• L1499 - Spinal orthosis, not otherwise specified
• L2999 - Lower extremity orthosis, not otherwise specified
• L3999 - Upper limb orthosis, not otherwise specified

Include in narrative: Loop 2400 (line note) or Item 19 of paper claim

• Description of the item
• Description of what makes item unique
• Breakdown of charges
  • For both materials and labor used in fabrication

If the claim is denied, request redetermination with all documentation to support medical necessity:

• Medical records showing necessity for item

See DMD article 3-D Printed Orthotic Devices - Correct Coding