Clinical UM Guideline
|Subject:||Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar|
|Guideline #:||CG-OR-PR-06||Current Effective Date:||06/28/2016|
|Status:||Revised||Last Review Date:||05/05/2016|
This document addresses the use of thoracic-lumbar-sacral (TLSO), lumbar-sacral (LSO), and lumbar spinal orthoses. These types of devices are back braces, which are used for many different purposes, including treatment of spinal column deformities, trauma, and back pain due to a variety of etiologies. This document addresses the use of back braces that are designed to immobilize or support various levels of the spine to treat back conditions.
Note: For information regarding the use of self-operated spinal unloading devices, including, but not limited to, gravity-dependent and pneumatic devices for the treatment of back pain, please see:
The use of prefabricated thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is considered medically necessary when any of the following conditions are met:
Custom fitted prefabricated spinal orthoses are considered medically necessary for the following indications:
Custom fabricated or custom molded spinal orthoses are considered medically necessary when all the criteria below are met:
Not Medically Necessary:
The use of any type of thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) or lumbar orthoses is considered not medically necessary when the medical necessity criteria above have not been met, including but not limited to all other conditions.
An upgrade would be considered a deluxe Durable Medical Equipment (DME) item and considered not medically necessary when its primary purpose is to allow the individual to perform leisure or recreational activities or includes comfort, luxury, or convenience features, or a feature which exceeds that which is considered medically necessary to treat the individual's condition.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|L0450-L0492||Thoracic-lumbar-sacral-orthoses (TLSO) [includes codes L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492]|
|L0625-L0627||Lumbar orthoses [includes codes L0625, L0626, L0627]|
|L0628-L0640||Lumbar-sacral orthoses (LSO) [includes codes L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640]|
|L0641-L0642||Lumbar orthoses [includes codes L0641, L0642]|
|L0643-L0651||Lumbar-sacral orthoses (LSO) [includes codes L0643, L0648, L0649, L0650, L0651]|
|L1000-L1005||Scoliosis procedures; cervical-thoracic-lumbar-sacral (CTLSO) orthotic devices [includes codes L1000, L1001, L1005]|
|L1200||Scoliosis procedures, thoracic-lumbar-sacral (TLSO) orthosis (low profile), inclusive of furnishing initial orthosis only|
|L1300||Other scoliosis procedure, body jacket molded to patient model|
|L1310||Other scoliosis procedure, postoperative body jacket|
|L1499||Spinal orthosis, not otherwise specified|
|L0970-L0982||Additions to spinal orthoses [includes codes L0970, L0972, L0974, L0976, L0978, L0980, L0982]|
|L0999||Addition to spinal orthosis, NOS|
|L1010-L1120||Additions to scoliosis CTLSO [includes codes L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120]|
|L1210-L1290||Additions to scoliosis TLSO (low profile) [includes codes L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290]|
Thoracic-lumbar-sacral orthoses (TLSO) and lumbar-sacral orthoses (LSO) have the following characteristics:
For an item to be classified as a TLSO, the posterior portion of the brace must extend from the sacrococcygeal junction to just inferior of 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 TLSO's may require the anterior portion to extend up to the sternal notch.
A spinal orthosis can be designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one of 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. Each type of movement is controlled by a placement of specific types of brace sections:
The documentation must show that the brace will immobilize the specific areas of the spine that is being treated.
A prefabricated orthosis is one which is manufactured in quantity without a specific individual in mind. Prefabricated spinal braces may not require the placement or adjustment by a trained orthotist. Examples of prefabricated orthoses include lumbosacral corsets, Knight spinal braces, and the CASH (cruciform anterior spinal hyperextension) brace.
A custom fitted orthosis is a particular type of prefabricated orthosis which is manufactured in quantity without a specific individual in mind, typically as a plastic torso shell, which has been trimmed, bent, molded (with or without heat), or otherwise modified for use by an appropriate licensed and trained medical professional subsequent to the taking of appropriate body measurements. An orthosis that is assembled from prefabricated components is considered prefabricated.
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 of the body part may be taken 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. Examples include the Milwaukee scoliosis brace, the Boston scoliosis brace, the Charleston scoliosis brace, and the Wilmington brace. Any orthosis that does not meet the definition of a custom fabricated orthosis is considered prefabricated.
A custom fabricated or custom molded orthosis is one which is individually made for a specific individual by a trained medical professional starting with basic materials including, but not limited to plastic, metal, leather, or cloth. It involves substantial work such as vacuum forming, cutting, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated plastic shell. A molded-to-individual orthosis is a specific type of custom fabricated or molded orthosis in which an impression of the specific body part is made by a trained medical professional using one of several methods, including plaster casting, anthropometric measurements, or computerized modeling. These methods are all used to create a model of the individual that is used to make a positive model of the body part being fitted with an orthosis. This positive model is used to custom fit a prefabricated orthosis.
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.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Copes Scoliosis Brace
Lumbar-Sacral Orthoses (LSO)
Providence Scoliosis System
SpineCor Dynamic Corrective Brace
Thoracic-Lumbar-Sacral Orthoses (TLSO)
Trunk Support Devices
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified the medically necessary statement to address the specific types of devices available. Clarified the necessary statement for custom fitted prefabricated braces to state that criteria for a prefabricated brace must also be met in addition to the criteria requiring underlying deformity or body somatotype which would preclude the use of a prefabricated brace. Added criteria to custom fabricated or custom molded spinal orthoses to require that the brace is prescribed for the treatment of a spinal deformity in a skeletally immature individual (for example, scoliosis). Updated Background section.|
|Reviewed||02/04/2016||MPTAC review. Updated Discussion section. Removed ICD-9 codes from Coding section.|
|Reviewed||02/13/2014||MPTAC review. Changed document # from CG-DME-11 to CG-OR-PR-06. Updated Reference section.|
|01/01/2014||Updated Coding section with 01/01/2014 HCPCS changes.|
|Reviewed||02/26/2009||MPTAC review. Coding updated.|
|Reviewed||03/08/2007||MPTAC review. Updated reference section. No change to clinical indications. Coding updated; removed HCPCS K0618, K0619, K0634-K0636, K0637-K0649 deleted 12/31/2005.|
|New||03/23/2006||MPTAC review. Initial document development.|
Last Review Date
|CT Durable Medical Equipment Coverage Criteria Guidelines: Spinal Orthoses: Thoracic-Lumbar-Sacral Orthoses (TLSO) and Lumbar-Sacral Orthorses (LSO) (Section J)|
|DME.705||West regional MDE Policy: Spinal Orthotics, TLSO and LSO|
|DME.013||Midwest Medical Review and Utilization Management Criteria: Spinal Othoses: Thoracic-Lumbar-Sacral Orthoses (TLSO) and Lumbar-Sacral Orthorses (LSO)|
|WellPoint Health Networks, Inc.|