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Section: Orthotic & Prosthetic Devices
Number: O-22
Topic: Spinal Orthosis
Effective Date: April 1, 2009
Issued Date: April 20, 2009

General Policy Guidelines | Procedure Codes | Coding Guidelines | References | Attachments | Procedure Code Attachments | Diagnosis Codes | Glossary

General Policy

A brace is a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured body part.

Spinal orthoses, also known as braces, are devices worn on the body to treat conditions such as scoliosis, back pain, and injury.  Most spinal orthoses are designed to adjust skeletal alignment, limit torso movement, and compress the stomach.

A variety of back supports or braces are designed to offer stabilization and decompression as a conservative treatment for pain related to spinal disc disease and/or joint dysfunction.

Orthoses for spinal injury are designed to protect the spinal column from loads and stresses that cause progression of the angular and translational deformity from the injury.

Indications and Limitations of Coverage

A thoracic-lumbar-sacral orthosis (L0450-L0492), lumbar orthosis (L0625-L0627) or lumbar-sacral orthoses (L0628-L0640) is covered when it is ordered for one of the following indications:

1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and be available upon request.  Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.

Reasons for Noncoverage

Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices.  Therefore, flexible spinal support garments billed with codes L0450, L0454, L0625, or L0628 that are made primarily of elastic material (e.g., neoprene or spandex [elastane, Lycra™ ] will be denied as noncovered, no benefit coverage. Flexible spinal orthoses that are made primarily of nonelastic material (e.g., cotton or nylon) or that have a rigid posterior panel remain eligible for coverage. A provider can bill the member for the denied service.

A protective body sock (L0984) does not meet the definition of a brace and is noncovered. A network provider can bill the member for the denied service.

There is no separate payment if CAD-CAM technology is used to fabricate an orthosis.  Reimbursement is included in the allowance of the codes for custom fabricated orthoses.

Documentation Requirements

If a flexible garment billed with code L0450, L0454, L0625, or L0628 is made primarily of elastic material (e.g., neoprene or spandex [elastane, Lycra™], the GY modifier must be added to the code.  If a flexible spinal orthosis billed with code L0450, L0454, L0625, or L0628 is made primarily of nonelastic material (e.g., cotton or nylon or has a rigid posterior panel, the CG modifier must be added to the code.

Procedure Codes

Coding Guidelines

L0452, L0478-L0486, L0629, L0632, L0634, L0638 and L0640 describe custom fabricated orthoses.  These codes must not be used for prefabricated/custom fitted orthoses.

There is no separate billing if CAD-CAM technology is used to fabricate an orthosis. 

References

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

A9270L0450L0452L0454
L0456L0458L0460L0462
L0464L0466L0468L0470
L0472L0480L0482L0484
L0486L0488L0490L0491
L0492L0625L0626L0627
L0628L0629L0630L0631
L0632L0633L0634L0635
L0636L0637L0638L0639
L0640L0984  

Diagnosis Codes

Glossary

TermDescription

Body Jacket Type Orthoses

In addition to (1) and (2)of the thoracic-lumbar-sacral orthosis, the body jacket type orthoses (L0458-L0464,  L0480-L0492, L0639-L0640) are characterized by a rigid plastic shell that encircles the trunk with overlapping edges and stabilizing closures and provides a high degree of immobility.  The entire circumference of the plastic shell must be the same rigid material.

 

Coronal Control

Coronal control is achieved by a rigid panel in the mid-axillary line which is either an integral part of a posterior or anterior panel or a separate panel.  Transverse control is achieved by one of several possible structural features:

  1. A rigid panel in the upper sternal area which is an integral part of an anterior shell, or
  2. A rigid panel in the upper sternal area which is rigidly attached to rigid abdominal or posterior panel, or
  3. Rigid extensions from a rigid posterior panel to the upper anterior chest bilaterally.  Straps over the shoulders attaching to a posterior panel do not provide transverse control.
     

Custom Fabricated Orthosis

 A custom fabricated orthosis is one which is individually made for a specific patient (no other patient would be able to use this orthosis) starting with basic materials including, but no limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc.  It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc.  It requires more than trimming, bending, or making other modifications to a substantially prefabricated item.  A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis in which either:

  1. An impression of the specific body part is made (usually by means of a plaster or fiberglass cast) and this impression is then used to make a positive model (usually of plaster) of the body part; or
  2. Detailed measurements are taken of the patient’s torso and are used to modify a positive model (which has been selected from a large library of models) to make it conform to the patient’s body shape and dimensions; or
  3. A digital image of the patient’s torso is made using computer (CAD-CAM) software which then directs the carving of a positive model.

The orthosis is then individually fabricated and molded over the positive model of the patient.

L0452, L0478-L0486, L0629, L0632, L0634, L0636, L0638 and L0640 describe custom fabricated orthoses.  These codes must not be used for prefabricated/custom fitted orthoses.

There is no separate billing if CAD-CAM technology is used to fabricate an orthosis.

 

Prefabricated Orthosis

A prefabricated orthosis is one which is manufactured in quality without a specific patient in mind.  It is preformed with a shape that generally conforms to the body part.  A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient (i.e., custom fitted).  A preformed orthosis is considered prefabricated even if it requires the attachment of straps and/or the addition of a lining and/or finishing work.  Multiple measurements may be taken of the body part to determine which stock size of a prefabricated orthosis will provide the best fit.  An orthosis that is assembled from prefabricated components is considered prefabricated.  Any orthosis that does not meet the definition of a custom fabricated orthosis is considered prefabricated.

 

Sagittal Control

Sagittal control is achieved by a rigid posterior panel.


Spinal Orthosis

A spinal orthosis can be designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one or more planes of motion:  Lateral/flexion (side bending) in the coronal/frontal plane, flexion (forward bending) or extension (backward bending) in the sagittal plane and axial rotation (twisting) in the transverse plane.

If the product does not provide control of motion in one or more planes or does not provide intracavitary pressure, then the item is not considered a spinal orthosis and should be coded as A9270.  The provider cannot bill the member for the denied service.

 

Thoracic–Lumbar-Sacral Orthoses

Thoracic-lumbar-sacral orthoses (TLSO) described by codes L0450-L0492, lumbar orthoses (LO) described by codes L0625-L0627 and lumbar-sacral orthoses (LSO) described by codes L0628-L0640 have the following characteristics:

1. Used to immobilize the specified areas of the spine.
2. Intimate fit and generally designed to be worn under clothing.
3. Not specifically designed for patients in wheelchairs.

For an item to be classified as a TLSO the posterior portion of the brace must extend from the sacrococcygeal junction to just inferior to the scapular spine.  This excludes elastic or equal shoulder straps or other strapping.  The anterior must at a minimum extend from the symphysis pubis to the xiphoid.  Some TLSOs may require the anterior portion to extend up to the sternal notch.
 






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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