Product Information ( Check brand and model , circle base code and addition ( s )): | |||||
� Arizona Optima Brace , Standard , Restricted |
� AZ CROW Walker ™ |
||||
R |
L |
L1970 An articulated molded plastic orthosis with |
R |
L |
L4631 A bivalved custom molded plastic orthosis , with |
ankle joints that allow for free motion of the ankle , |
a removable custom arch support , soft interface , and |
||||
( dorsi-plantar fl exion ), custom molded from a model |
a rocker bottom walking sole . For patients with Charcot . |
||||
of the patient , custom fabricated , includes casting and cast |
� Split Upright AFO |
||||
preparation . |
R |
L |
L1970 An articulated molded plastic orthosis with |
||
R |
L |
L2820 Addition to lower extremity orthosis , soft interface for |
ankle joints that allow for free motion of the ankle , |
||
molded plastic below knee section . |
( dorsi-plantar fl exion ), custom molded from a model |
||||
� Arizona Thermoplastic AFO - Articulated , Dorsi-Assist |
of the patient , custom fabricated , includes casting |
||||
R |
L |
L1970 Articulated molded plastic orthosis with ankle joints , |
and cast preparation . |
||
custom molded from a model of the patient , includes casting |
R |
L |
L2820 Addition to lower extremity orthosis , soft interface |
||
and cast preparation . |
for molded plastic below knee section |
||||
R |
L |
L2210 Addition to lower extremity , dorsi-fl exion assist |
� Split Upright AFO , Dorsi-Assist |
||
( plantarfl exion resist ), each joint . |
R |
L |
L1970 An articulated molded plastic orthosis with |
||
� Arizona Thermoplastic AFO - Articulated |
ankle joints that allow for free motion of the ankle , |
||||
R |
L |
L1970 An articulated molded plastic orthosis with |
( dorsi-plantar fl exion ), custom molded from a model of the |
||
ankle joints that allow for free motion of the ankle , |
patient , custom fabricated , includes casting and cast preparation . |
||||
( dorsi-plantar fl exion ), custom molded from a model of the |
R |
L |
L2210 Addition to lower extremity , dorsi-flexion assist |
||
patient , custom fabricated , includes casting and cast preparation . |
( plantarflexion resist ), each joint . |
||||
� Arizona Thermoplastic AFO |
R |
L |
L2820 Addition to lower extremity orthosis , soft interface for |
||
R |
L |
L1960 A molded plastic ankle foot orthosis , posterior solid ankle |
molded plastic below knee section |
||
trim lines , custom molded from a model of the patient , custom |
� Supramallleolar Orthosis |
||||
fabricated , includes casting and cast preparation |
R |
L |
L1907 Ankle orthosis , supramalleolar , with straps , |
||
with or without pads , custom fabricated |
|||||
DX : ( indicate all that apply ) - Corresponds to Biomechanical Examination Form | ||
|
Adult Acquired Flat Foot ( PTTD )
Flat foot [ pes planus ] ( acquired )
|
Foot Drop
Foot Drop , acquired
|
|
� right ( M21.41 ) |
� left ( M21.42 )
� right ( M21.371 )
� left ( M21.372 )
|
|
Spontaneous rupture of other tendons , ankle and foot |
Hemiplegia |
|
� right ( M66.871 ) |
� left ( M66.872 )
� affecting right dominant side ( I69.951 )
|
|
|
Disorder of ligament , ankle
� right ( M24.271 )
|
� affecting left dominant side ( I69.952 )
� left ( M24.272 )
� affecting right non-dominant side ( I69.953 )
|
|
Disorder of ligament , foot |
� affecting left non-dominant side ( I69.954 ) |
|