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

This policy addresses prefabricated spinal orthoses—thoracic-lumbar-sacral (TLSO), lumbar-sacral (LSO), and lumbar braces. These devices are covered as medically necessary when used to reduce pain by limiting trunk motion, facilitate healing after spinal/related soft-tissue injury or surgery, or support weak spinal muscles; they are not covered when these criteria are not met or when an “upgrade” constitutes deluxe DME primarily for comfort, convenience, or recreation, or includes features beyond what is medically necessary.

"The use ofprefabricatedthoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is consideredmedically necessarywhenanyof the following conditions are met:"

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