Clinical Guideline - Spinal Orthoses (Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar..) PDF Print E-mail

1. Description

Back braces are used for many different purposes including treating back pain and spinal column deformities.  This document addresses the use of back braces that are designed to immobilize or support various levels of the spine to treat back conditions.

2. Clinical Indications

2.1. Medically Necessary:

The use of prefabricated thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses with custom fitting is considered medically necessary when any of the following conditions are met:

  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 or a deformed spine.

Custom fabricated or molded spinal orthoses are considered medically necessary for the following indications:

  1. The treatment of scoliosis including, but not limited to, the use of scoliosis braces such as Milwaukee scoliosis braces, Boston scoliosis braces, Charleston scoliosis braces, and Wilmington braces; or
  2. If the patient has an underlying deformity or body somatotype which would preclude the use of a prefabricated brace.

2.2. Not Medically Necessary:

The use of prefabricated thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses including, but not limited to, the use of scoliosis braces such as Milwaukee scoliosis braces, Boston scoliosis braces, Charleston scoliosis braces, and Wilmington braces is considered not medically necessary when the medical necessity criteria above have not been met.

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 patient 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 patient's condition.

A custom fabricated or custom molded orthosis is considered not medically necessary for any indication not listed above in the section addressing these types of devices.

3. Discussion/General Information

Thoracic-lumbar-sacral orthoses (TLSO) and lumbar-sacral orthoses (LSO) 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 individuals in wheelchairs.

In addition to (1) and (2) above, the body jacket type orthoses 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.

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:

  • Sagittal control is achieved by a rigid posterior panel.
  • 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

A prefabricated orthosis is one which is manufactured in quantity without a specific patient in mind. A custom fitted orthosis is a particular type of prefabricated orthosis which has been trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient. 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 fitted orthosis is one which is manufactured in quantity (i.e., prefabricated) without a specific patient in mind.  A custom fitted orthosis may be trimmed, bent, molded or otherwise modified for use by a specific patient.  An orthosis that is assembled from prefabricated components for a specific patient is also considered 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 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. 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 patient starting with basic materials including, but not limited to plastic, metal, leather, or cloth.  It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item.

A molded-to-patient orthosis is a specific type of custom fabricated orthosis in which an impression of the specific body part is made using one of several methods, including plaster casting, anthropometric measurements, or computerized modeling. These methods are all used to create a model of the patient 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.

4. Coding

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.

If you need information regarding DME Billing Code Click Here. Diagnosis Code Click Here

HCPCS
Orthoses
L0450-L0492 Thoracic-lumbar-sacral-orthoses (TLSO) [includes codes L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, 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]
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
Additions/Accessories
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]
ICD-9 Diagnosis
All diagnoses

article reference: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_a053624.htm

 

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