PME catalog for print (1)

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.


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


• 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




5



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


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









Universal Sizing

6



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 L0462 Recommend HCPCS Code L1005 Recommend HCPCS Code L3660

0215 0216 0217



one size fits all one size fits all



7



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 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 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.


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


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



• Supports finger, hand and wrist• Easily adjust internal aluminum stay• For functional/resting use

Air Soft Resting Hand Splint0225



9



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



one size fits allone size fits all

10





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



HIP

one size fits all

11

BE SURE TO CHECK THE CONDITIONS AND CRITERIA ON PAGE 20 AND 21 BEFORE MAKING SELECTION.


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



02400239 0241



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


0238


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.


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

• 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




13



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



CERVICAL COLLAR

14

ITEM # SIZE CHART UNDERLYING CONDITIONS AND COVERAGE CRITERIA

INDEX


Size Knee Circumference*

Small 12.5” - 14.5”

Medium 14” - 16”

Large 15.5” - 18”

X Large 17.5” - 20”


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”


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”


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”







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



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









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



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”







*Thigh circumference should be measured approximately 6” above knee

KN

EE

16


INDEX


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)


Sm-XL 26”-52”

Extender belt Up to 75”

14” Back Panel

Size

Universal Sizing

Size

Universal Sizing


X-Small 26”-32”

Small 32”-36”

Medium 36”-40”

Large 40”-44”


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


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


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


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


UNDERLYING CONDITIONS: Scoliosis OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve spinal function. (Not preventative.)


UNDERLYING CONDITIONS: Fracture of clavicle OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)


SP

INE

/BA

CK

*Measure the chest circumference at the sternum area


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



Size

Universal Sizing

Size

Universal Sizing

Size Bicep Circumference

Adult 11”-15”


Adult Small 9”-12”

Adult 11”-15”


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.)


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.)


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.)


UNDERLYING CONDITIONS: Fracture of clavicle OtherCOVERAGE CRITERIA: Orthosis is for treatment of illness or injury or to improve upper body function. (Not preventative.)


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.)


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.)


ELB

OW

/SH

OU

LDE

R

18


INDEX


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


Small 2.5”-3” 10”

Medium 3”-3.5” 11”

Large 3.5”-4” 12”

Functional resting & Grip


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.)


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.)


Size Measurement

Small 2¼” - 2¾”

Medium 27/8” - 3¼”

Large 33/8” - 3¾”

0225-Air Soft Resting Hand Splint


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



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.)


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.)


WR

IST/

HA

ND


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.)


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.)



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.)


20


INDEX


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.)


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.)


UNDERLYING CONDITIONS: Hip Osteoarthritis OtherCOVERAGE CRITERIA: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.)


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


* 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


21

INDEX



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








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+


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


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


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


INDEX


0244-Posterior Night Splint


Small 4-6 5-7

Medium 6-10 7-11

Large 10-13 11-14

0245-Dorsal Night Splint


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.)


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.)


CA

M W

ALK

ER

/NIG

HT

SP

LIN

TC

ER

VIC

AL

CO

LLA

R


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



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: / /


P: 877-303-8050

F: 732-348-1150

E: [email protected]

A: 1995 Rutgers University Blvd

Lakewood, NJ 08701

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