Spinal Orthoses (Lumbar Sacral and Thoraco Lumbar Sacral) - DME.MU.111.A

Covers lumbar‑sacral and thoraco‑lumbar‑sacral spinal orthoses for patients with spine or soft‑tissue injury, post‑spine surgery, to restrict spinal movement and reduce pain, or with spinal deformity/weak spinal muscles. Coverage is limited to the HCPCS codes listed in the policy (L0450–L0651); no additional exclusions, frequency limits, age restrictions, or specific documentation requirements are stated in the provided text.

"A spinal orthosis may be indicated when one of the following applies:"

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