L0623, Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid
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.
- Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit.
2 Active Policies
L33790, Spinal Orthoses: TLSO and LSO
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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