L0637 — Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, 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.