Medicare Advantage

Medical Policy

Notification

Spinal Orthoses

Notification Issue Date: 5/19/2026 10:00 AM

This version of the policy will become effective 08/18/2026.

Face-to-Face Requirement language and documentation requirements have been removed for HCPCS codes:

L0457- TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf
L4000- Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis) or shoulder orthosis

The Billing Requirements have been revised to:

The CG modifier must be added to code L0450, L0454, L0455, L0621, L0625, or L0628 only if it is one made primarily of nonelastic material (e.g., canvas, cotton or nylon) or having a rigid posterior panel.

Title:

Spinal Orthoses

Policy #:

MA05.030g

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

Thoracic-lumbar-sacral orthosis (TLSO) and lumbar-sacral orthosis (LSO) are spinal orthoses that meet Medicare's definition of a brace and are considered medically necessary and, therefore, covered for any of the following indications:

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

COVERED

Flexible spinal orthoses that are made primarily of nonelastic material (e.g., canvas, cotton, or nylon) or that have a rigid posterior panel are eligible for coverage.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Orthotic training may include teaching the individual regarding a wearing schedule, placing and removing the orthosis, skin care and performing tasks while wearing the device. It is not appropriate to include the time spent assessing, measuring or fitting, fabricating or modifying, or making the orthotic in the time spent providing orthotic training. Only the time spent actually training the individual should be included in the orthotic training service.

Evaluation of the individual, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.

NOT MEDICALLY NECESSARY

The use of a spinal orthosis for all other conditions is considered not medically necessary and, therefore, not covered.

NOT COVERED

The following items are not covered by the Company because they are items not covered by Medicare. They do not meet Medicare's definition of a brace (i.e., a rigid or semi-rigid device). Therefore, the items are not eligible for reimbursement consideration.

Belt, strap, sleeve, garment, or covering, any type
Elastic support garments that are made primarily of elastic material (e.g., neoprene or spandex [elastane, Lycra™])
A protective body sock
Stocking supporter grips
Peroneal straps

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face encounter with the individual for whom the item is ordered that meets all of the following requirements:

The treating professional provider must have an in-person encounter with the individual within the 6 months prior to the date of the written order prior to delivery.
This encounter must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of durable medical equipment (DME) ordered.

A new face-to-face encounter is required each time a new standard written order for one of the specified items is ordered. A new standard written order is required:

For all claims for purchases or initial rentals
When there is a change in the standard written order for the accessory, supply, drug, etc.
If periodic standard written order renewal required per medical policy
When an item is replaced
When there is a change in the supplier

In this policy the specified items are:

Code	Narrative
L0631	Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0635	Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
L0636	Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated
L0637	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0638	Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated
L0639	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0640	Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated
L0648	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
L0650	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
L0651	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

For custom-fabricated orthoses, there must be detailed documentation in the treating professional provider’s records to support the medical necessity of a custom-fabricated rather than a prefabricated orthosis.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

BILLING REQUIREMENTS

The CG modifier must be added to code L0450, L0454, L0455, L0621, L0625, or L0628 only if it is one made primarily of nonelastic material (e.g., canvas, cotton or nylon) or having a rigid posterior panel.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, a spinal orthosis is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

Description

An orthosis (brace) is a rigid or semi-rigid device. The purpose of the brace is to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured area of the body. An orthosis (brace) must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace.

A spinal orthosis is 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. Control of this plane is achieved by a rigid panel in the midaxillary line, which is either an integral part of a posterior or anterior panel, or a separate panel.
Anterior flexion (forward bending) or posterior extension (backward bending) in the sagittal plane. Control of this plane is achieved by a rigid posterior panel.
Axial rotation (twisting) viewed in the transverse plane. Straps over the shoulders attaching to a posterior panel alone do not provide transverse spinal control.

Thoracic-lumbar-sacral orthoses (TLSO) and lumbar-sacral orthoses (LSO) have the following characteristics:

Used to immobilize the specified areas of the spine
Intimate fit and generally designed to be worn under clothing
Not specifically designed for individuals 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 methods. The anterior portion of the orthosis must at a minimum extend from the symphysis pubis to the xiphoid. Some TLSOs may require the anterior portion of the orthosis to extend up to the sternal notch.

A prefabricated orthosis is one that is manufactured in quantity without a specific individual in mind. It is pre-formed 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 individual (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 other 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.

A custom-fabricated orthosis is one that is individually made for a specific individual (no other individual would be able to use this orthosis), starting with basic materials including, but not 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-individual-model orthosis is a particular type of custom-fabricated orthosis in which either:

An impression of the specific body part is made (usually by means of a plaster or fiberglass cast) and then used to make a positive model (usually of plaster) of the body part.
Detailed measurements are taken of the individual’s torso and are used to modify a positive model (that has been selected from a large library of models) to make it conform to the individual’s body shape and dimensions.
A digital image of the individual’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 individual.
- Modern CAD-CAM and rapid fabrication technologies used in the prosthesis and orthotics manufacturing are based on 3D scanning, 3D reconstruction, and computer-aided fabrication.

References

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2022; Final Rule. [Federal Register Web site]. Original: 11/08/2019. (Revised: 05/13/2024). Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/FINAL-RULE-MASTER-LIST-of-DMEPOS-Subject-to-Frequent-Unnecessary-Utilization-2018-03-30.pdf. Accessed March 31, 2026.

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to the Master List of Items Potentially Subject to Face-to-Face Encounter and Written Order Prior To Delivery and/or Prior Authorization Requirements; Updates to the Required Face-to-Face and Written Order Prior To Delivery List; and Updates to the Required Prior Authorization List [Federal Register Web site]. 05/13/2024. Available at: https://www.federalregister.gov/documents/2024/05/13/2024-10356/medicare-program-updates-to-the-master-list-of-items-potentially-subject-to-face-to-face-encounter. Accessed March 31, 2026.

Centers for Medicare & Medicaid Services (CMS). Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment. 05/13/2024. Available at: https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/master-list-dmepos-items-potentially-subject-conditions-payment. Accessed March 31, 2026.

Noridian Healthcare Solutions. Local Coverage Article (A52500). Spinal orthoses: TLSO and LSO. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/23/2024). Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52500&ContrID=140. Accessed March 31, 2026.

Noridian Healthcare Solutions. Local Coverage Determination (L33790). Spinal orthoses: TLSO and LSO. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 1/01/2020). Available at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33790&ver=20. Accessed March 31, 2026.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

L0452 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated

L0454 TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0455 TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0457 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf

L0458 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysispubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0460 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0462 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0464 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 4 rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0466 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0467 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf

L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0469 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf

L0470 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0472 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with 2 anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0480 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0482 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0484 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0486 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0488 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment

L0490 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, 1 piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

L0491 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0492 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf

L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf

L0624 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf

L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0629 Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated

L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0631 Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0632 Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0634 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated

L0635 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0636 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated

L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0638 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0640 Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated

L0641 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0642 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0643 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0649 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf

L4000 Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis (CTLSO) or spinal orthosis SO)

L4002 Replacement strap, any orthotic, includes all components, any length, any type

NOT COVERED

A4467 Belt, strap, sleeve, garment, or covering, any type

L0980 Peroneal straps, prefabricated, off-the-shelf, pair

L0982 Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)

L0984 Protective body sock, prefabricated, off-the-shelf, each

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

CG Policy criteria applied

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA05.030g:

08/18/2026

This version of the policy will become effective 08/18/2026.

Face-to-Face Requirement language and documentation requirements have been removed for HCPCS codes:

L0457- TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf
L4000- Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis) or shoulder orthosis

The Billing Requirements have been revised to:

Revisions From MA05.030f:

04/02/2025	This policy has been reissued in accordance with the Company's annual review process.
08/12/2024	The version of the policy will become effective 08/12/2024. In accordance with Medicare Final Rule: Face-to-Face Requirement language has been added for HCPCS codes L0457, L0631, L0635, L0636, L0637, L0638, L0639, L0640, L0648, L0650 and L0651. HCPCS code L4000: Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis) or shoulder orthosis, has been added to the policy as Medically Necessary and to the Face-to-Face Requirement language

04/02/2025

This policy has been reissued in accordance with the Company's annual review process.

08/12/2024

The version of the policy will become effective 08/12/2024.

In accordance with Medicare Final Rule:

Face-to-Face Requirement language has been added for HCPCS codes L0457, L0631, L0635, L0636, L0637, L0638, L0639, L0640, L0648, L0650 and L0651.
HCPCS code L4000: Replace girdle for spinal orthosis (cervical-thoracic-lumbar-sacral orthosis) or shoulder orthosis, has been added to the policy as Medically Necessary and to the Face-to-Face Requirement language

Revisions From MA05.030e:

02/07/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
07/03/2023	The version of the policy will become effective 07/03/2023. Face-to-Face Requirement language and documentation requirements have been removed for HCPCS codes L0635, L0636, L0638, L0639, L0640 and L0651 in accordance with the 2023 CMS New Final Rule on Face-to-Face Encounters. To be consistent with Medicare, non-covered criteria in the policy has been revised and HCPCS codes L0980 and L0982 have been added to the policy as non-covered.

Revisions From MA05.030d:

06/29/2022	The policy has been reviewed and reissued to communicate the Company's continuing position of Spinal Orthoses.
08/02/2021	This version of the policy will become effective 08/02/2021. The policy has been updated to communicate the Company's continuing position on Spinal Orthoses. In accordance with Medicare, Face-to-Face Requirement language has been added for HCPCS codes L0631, L0635, L0636, L0637, L0638, L0639, L0640, L0648, L0650 and L0651 and documentation requirements per CMS New Final Rule. In accordance with Medicare, HCPCS codes L0622 and L0624 have been added as "Medically Necessary".

06/29/2022

The policy has been reviewed and reissued to communicate the Company's continuing position of Spinal Orthoses.

08/02/2021

This version of the policy will become effective 08/02/2021.

The policy has been updated to communicate the Company's continuing position on Spinal Orthoses.

In accordance with Medicare, Face-to-Face Requirement language has been added for HCPCS codes L0631, L0635, L0636, L0637, L0638, L0639, L0640, L0648, L0650 and L0651 and documentation requirements per CMS New Final Rule.

In accordance with Medicare, HCPCS codes L0622 and L0624 have been added as "Medically Necessary".

Revisions From MA05.030c:

02/13/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Spinal Orthoses.
03/14/2018	The policy has been reviewed and reissued to communicate the Company’s continuing position on spinal orthoses.
02/08/2017	The policy section was revised to reflect the non-coverage of HCPCS code A4467

Revisions From MA05.030b:

01/01/2017

The following HCPCS code has been deleted from this policy:

A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each

The following HCPCS code has been added to this policy:

A4467 Belt, strap, sleeve, garment, or covering, any type

Revisions From MA05.030a:

02/03/2016

The policy has been reviewed and reissued to communicate the Company’s continuing position on spinal orthosis.

07/31/2015

The following policy sections have been revised:

The policy description
The policy language modified; the intent of this policy remains unchanged.
The required documentation.
The coding and billing requirements section.

The following HCPCS codes have been added to this policy:

L0455, L0457, L0467, L0469, L0623, L0641, L0642, L0643, L0648, L0649, L0650, and L0651

The following HCPCS code has been revised in this policy:

FROM: L0984 Protective body sock, each
TO: L0984 Protective body sock, prefabricated, off-the-shelf, each

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Revisions From MA05.030:

01/01/2015

This is a new policy.

Version Effective Date:

8/18/2026

Version Issued Date: