L0467 — Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf
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.
- Suppliers must maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.
Key Coverage Criteria
- Spinal orthoses (listed HCPCS codes) are covered when ordered to reduce pain by restricting mobility of the trunk.
- Spinal orthoses are covered when ordered to facilitate healing after an injury to the spine or related soft tissues.
- Spinal orthoses are covered when ordered to facilitate healing following a surgical procedure on the spine or related soft tissue.
- Spinal orthoses are covered when ordered to support weak spinal muscles and/or a deformed spine.
- An item is covered only if it meets Medicare prerequisites: is in a defined Medicare benefit category, is reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meets other applicable Medicare statutory and regulatory requirements.
- The use ofprefabricatedthoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is consideredmedically necessarywhenanyof the following conditions are met:
3 Active Policies
L33790 — Spinal Orthoses: TLSO and LSO
J19
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
ANTHEM-CG-DME-11 — CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
Related Codes
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