L1005, Tension based scoliosis orthosis and accessory pads, includes fitting and
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Patient-reported outcome measures (PROMs) where applicable: SRS-22, SF-36, and other quality-of-life scores (many comparative studies collected SRS-22 and SF-36 scores; Pehlivanoglu et al 2021b; Rushton et al 2021).
- Pulmonary function tests where relevant (some cohorts lacked complete PFT results and this limited analyses; Qiu et al 2021 noted incomplete PFTs in fusion cohort).
- Documentation of indications for MCGR/MAGEC including rationale that instrumented fusion would result in unacceptable reduction in final height or respiratory function and confirmation of age/bone age criteria when used (NHS guidance).
- There are no explicit documentation requirements stated in this document. (No section titled "Documentation Requirements" is present in the provided text.)
Key Coverage Criteria
- Aetna considers the following types of braces and casts medically necessary durable medical equipment (DME) for the treatment of scoliosis: Standard thoracolumbosacral orthosis (TLSO).
- 22548 (listed in the table — appears under covered codes)
- Aetna considers surgery (e.g., spinal fusion with instrumentation and bone grafting) for the treatment of idiopathic scoliosis medically necessary for any of the following conditions: Idiopathic scoliosis with curve greater than or equal to 40 degrees in an adolescent younger than age 18;
- Aetna considers surgery (e.g., spinal fusion with instrumentation and bone grafting) for the treatment of idiopathic scoliosis medically necessary for any of the following conditions: Idiopathic scoliosis with curve greater than or equal to 50 degrees in a young adult age 18 to 25.
- Aetna considers growing rods technique medically necessary in the treatment of idiopathic scoliosis for persons who meet criteria for surgery above (includes the MAGEC System).
- An orthosis (orthopedic brace) and/or prosthesis is medically necessary when: Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to state law;
3 Active Policies
ANTHEM-CG-DME-11, CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar
AETNA-CPB-0398, Idiopathic Scoliosis
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.