L1001 — Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- The use ofprefabricatedthoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is consideredmedically necessarywhenanyof the following conditions are met:
- To reduce pain by restricting mobility of the trunk;or
- To facilitate healing following an injury to the spine or related soft tissues;or
- To facilitate healing following a surgical procedure on the spine or related soft tissue;or
- To otherwise support weak spinal muscles.
- Custom fitted prefabricatedspinal orthoses are consideredmedically necessaryfor the following indications:
2 Active Policies
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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