Spinal Orthoses (Thoracic-Lumbar Sacral, Lumbar, Lumbar-Sacral and Sacroiliac) - DME.MU.111.A

Evicore covers prefabricated, prefabricated-with-custom-fitting, and custom‑fabricated thoracic‑lumbar/sacral and sacroiliac orthoses for spine injury/surgery, bony spine disease, trunk stabilization that improves function, selected nonoperative thoracolumbar fractures, and adolescent idiopathic scoliosis meeting Cobb/Risser criteria, but excludes braces solely for low back pain, prophylactic or elastic/fabric supports (HCPCS A4467), protective body socks (L0984), the SpineCor® brace, duplicate orthoses, and investigational devices. Coverage requires clinical documentation of the indication and functional benefit (for AIS: x‑ray with Cobb angle and Risser 0–2 and documented progression or justification), custom fabrication requires clinically‑derived casts/CAD‑CAM positive models or inability to fit a prefabricated device or anticipated permanence >6 months, and replacements require a recent provider visit with a documented care plan plus growth/change, loss/theft, or irreparable/unwarrantied damage.