L0628 |
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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
short | Lso flex no ri stays pre ots |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0629 |
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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, custom fabricated
short | Lso flex w/rigid stays cust |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0630 |
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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
short | Lso r post pnl sj-t9 pre cst |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0631 |
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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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
short | Lso sag r an/pos pnl pre cst |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0632 |
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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, custom fabricated
short | Lso sag rigid frame cust |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0633 |
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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
short | Lso sc r pos/lat pnl pre cst |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0634 |
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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/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
short | Lso flexion control custom |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0635 |
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Lumbar-sacral orthosis, 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
short | Lso sagit rigid panel prefab |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0636 |
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Lumbar sacral orthosis, 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
short | Lso sagittal rigid panel cus |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0637 |
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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
short | Lso sc r ant/pos pnl pre cst |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0638 |
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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, custom fabricated
short | Lso sag-coronal panel custom |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0639 |
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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
short | Lso s/c shell/panel prefab |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L0640 |
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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, custom fabricated
short | Lso s/c shell/panel custom |
MUE | Location | Value | Ajudication Indicator | Rationale |
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PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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