L0454 — Tlso flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before claim submission for items addressed in this policy.
- For DMEPOS base items that require WOPD, the supplier must have received a signed Written Order Prior to Delivery (WOPD) before delivering the DMEPOS item.
- For base items with separately billed options/accessories/supplies, the WOPD must list the base item and may list associated separately billed items prior to delivery.