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HCPCS/CPT L1280 — Addition to tlso, (low profile), rib gusset (elastic), each | No Prior Auth

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`L1280` — Addition to tlso, (low profile), rib gusset (elastic), each

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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:

1 Active Policy

ANTHEM-CG-DME-11 — CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar

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