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Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

HCPCS code

Medical Policies and Guidelines for Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated

Related policies from health plans

Noncovered Investigational Services
Noncovered Investigational Services(Eff. beginning 1.1.24)
Prosthetic Devices – Upper Limb Prostheses

Similar Codes


ICD10CM codes

G56.00 - Carpal tunnel syndrome, unspecified upper limb
S58.129 - Partial traumatic amputation at level between elbow and wrist, unspecified arm
G90.519 - Complex regional pain syndrome I of unspecified upper limb
G56.01 - Carpal tunnel syndrome, right upper limb
G90.511 - Complex regional pain syndrome I of right upper limb
S58.121 - Partial traumatic amputation at level between elbow and wrist, right arm
S58.111 - Complete traumatic amputation at level between elbow and wrist, right arm
G90.51 - Complex regional pain syndrome I of upper limb
S58.12 - Partial traumatic amputation at level between elbow and wrist
G90.513 - Complex regional pain syndrome I of upper limb, bilateral

HCPCS codes

L8702 - Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double
L3730 - Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated
L3720 - Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated
L6635 - Upper extremity addition, lift assist for elbow
L3740 - Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control,
E1801 - Static progressive stretch elbow device, extension and/or flexion, with or without range of motion a
L3765 - Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom
L3766 - Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles
L3900 - Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexio
L3763 - Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabrica

CPT4 codes

29584 - Application of multi-layer compression system; upper arm, forearm, hand, and fingers
29583 - Application of multi-layer compression system; upper arm and forearm
95852 - Range of motion measurements and report (separate procedure); hand, with or without comparison with
95851 - Range of motion measurements and report (separate procedure); each extremity (excluding hand) or eac
73201 - Computed tomography, upper extremity; with contrast material(s)
29260 - Strapping; elbow or wrist
15878 - Suction assisted lipectomy; upper extremity
29075 - Application, cast; elbow to finger (short arm)
25446 - Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)
73200 - Computed tomography, upper extremity; without contrast material