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Insurance ID#
Ordering Physician
Doctors Name
Dr. Lyubov Moysik
Dr. Isaac Kreizman
Npi Number
1053429167
1497825434
Doctors Address
3000 Ocean Pkwy, Brooklyn, NY 11235
5223 9th Ave, Brooklyn, NY 11220
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Medical Supply Request
Chief Complaint
*
Upper extremity
Lower extremity
Icd 10 Diagnosis
*
Lower Back Pain, M54.5
DJD LumbarSacral, M51.37
Radiculopathy, L5-S1, M54.17
Disc Herniation, M51.27
OA DJD, M17.0
Sprain & Strain of Knee, S83.429A
Knee Instability, M23.50
Tear of Medial Meniscus, M23.203
Cervicalgia, M54.2
Cervical Radiculopathy, M54.12
Pain in shoulder, M25.519
Carpal Tunnel G56.00
Tendinitis [de Quervain] M65.4
Wrist Pain / Arthritis M25.539
Ankle Pain, M25.579
Ankle Sprain, S93.409A
Osteoarthritis M19.079
Other
Fitting
*
Custom Fitted
Off the Shelf
Ordered Supplies
*
L0456/L0547 - TLSO w Shoulder straps
L0650/L0637 - Lumbar Sacral Orthosis (APL)
L0648/L0631 - Lumbar Sacral Orthosis (AP)
L0642/L0627 - Lumbar Orthosis (AP)
L1833/L1832 - Knee Orthosis Adj.
L2397 - Knee sleeve, accessory
L2810 x2 - Condylar Pad, accessory
L3916/L3915 - Wrist Hand Orthosis Adj.
L2116 - Rigid Cam Walker
L3670 - Shoulder Immobilizer
L0172/L0174 - Cervical Collar 2 piece
E0730 - Tens Unit kit
L1906/L1971 - Hinged Ankle Brace
L1902 - Ankle Support
A6530 - Knee High Stockings
Quantity
*
Right
Left
Bilateral
One Unit
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Medical Necessity
To improve/maintain/control alignment. Protect a body segment from further injury. Required for producing intracavitary pressure to reduce the load on the lumbar intervertebral discs. To protect a body segment from further injury. Required for immobilizing and reducing pain, Conservative treatment options include physical therapy, bracing, steroid injections, and alternative medicine.
To improve/maintain/control alignment. Protect a body segment from further injury. The patient needs the equipment/supplies to reduce pain by restricting the mobility of the knee to provide support and stability. The patient has pain and discomfort from a history of injuries/falls, a knee brace will help prevent injury/falls. The device is to be worn immediately.
The patient needs the equipment/supplies to reduce pain by restricting the mobility of the ankle to provide support and stability. The patient has pain and discomfort from a history of injuries/falls, an ankle brace will help prevent injury/falls. The device is to be worn immediately.
To improve/maintain/control alignment. Protect a body segment from further injury. Required for immobilizing and reducing pain, Conservative treatment options include physical therapy, bracing, steroid injections, and alternative medicine.
Plan of Care
The patient needs an off-the-shelf LSO to reduce pain by restricting the mobility of the trunk and to provide support and stability for the lumbar-sacral region. The device is to be worn immediately.
The patient needs a custom-fitted LSO to reduce pain by restricting the mobility of the trunk and to provide support and stability for the lumbar-sacral region. The device is to be adjusted, molded or bent for optimal fit to the patient, device to be worn immediately.
Off-the-shelf knee brace with adjustable hinges and accessories to improve/maintain/control alignment. Protect a body segment from further injury. Required for reducing pain by reducing the load on the medial side of the knee.
Custom-fitted Knee brace with adjustable hinges and accessories to improve/maintain/control alignment. Protect a body segment from further injury. Required for reducing pain by reducing the load on the medial side of the knee. The device is to be adjusted, molded or bent for optimal fit to the patient, device to be worn immediately.
The patient needs an off-the-shelf wrist hand thumb brace to reduce pain by restricting the mobility of the wrist and to provide support and stability. The device is to be worn immediately.
The patient needs a custom-fitted wrist hand thumb brace to reduce pain by restricting the mobility of the wrist and to provide support and stability. The device is to be adjusted, molded or bent for optimal fit to the patient, device to be worn immediately.
The patient needs an off-the-shelf shoulder sling with an abduction pillow to reduce pain by restricting the mobility of the shoulder and to provide support and stability. The device is to be worn immediately.
The patient needs an off-the-shelf Cervical Collar to reduce pain by restricting the mobility of the neck and to provide support and stability. The device is to be worn immediately.
The patient needs a custom-fitted Cervical Collar to reduce pain by restricting the mobility of the neck and to provide support and stability. The device is to be adjusted, molded or bent for optimal fit to the patient, device to be worn immediately.
The patient needs the equipment/supplies to reduce pain by restricting the mobility of the ankle to provide support and stability. The patient has pain and discomfort from a history of injuries/falls, an ankle brace will help prevent injury/falls. The device is to be worn immediately.
The patient needs the equipment/supplies to reduce pain by restricting the mobility of the ankle to provide support and stability. The patient has pain and discomfort from a history of injuries/falls, an ankle brace will help prevent injury/falls. The device is to be custom-fitted; adjusted, molded or bent for optimal fit to the patient, device to be worn immediately.
Use as Directed
Patient was instructed to wear their product only when they are in severe pain or when they are going to do an activity that creates pain, but no more than 50% of their waking hours unless they were directed to do otherwise.
Patient was instructed to break in their product over a 3-week period – Week 1 – wear no more than 2 hours at a time Week 2 – wear no more than 3 hours at a time Week 3 – wear no more than 4 hours at a time, and so on.
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