Browse HCPCS Level II 2020 Edition

HCPCS Level II Table of Contents

L0450 - L0492  Orthotic Devices - Thoracic-Lumbar-Sacral

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
shortTlso flex trunk/thor pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0452
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
shortTlso flex custom fab thoraci
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso trnk sj-t9 pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso flex trnk sj-t9 pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso flex trnk sj-ss pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso flex trnk sj-ss pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0458
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 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
shortTlso 2mod symphis-xipho pre
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso 2 shl symphys-stern cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0462
Tlso, triplanar control, modular segmented spinal system, three 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
shortTlso 3mod sacro-scap pre
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0464
Tlso, triplanar control, modular segmented spinal system, four 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
shortTlso 4mod sacro-scap pre
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso r fram soft ant pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso r fram soft pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso rig fram pelvic pre cst
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
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
shortTlso rig fram pelvic pre ots
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0470
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
shortTlso rigid frame pre subclav
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0472
Tlso, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two 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
shortTlso rigid frame hyperex pre
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0480
Tlso, triplanar control, one 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
shortTlso rigid plastic custom fa
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0482
Tlso, triplanar control, one 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
shortTlso rigid lined custom fab
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0484
Tlso, triplanar control, two 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
shortTlso rigid plastic cust fab
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0486
Tlso, triplanar control, two 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
shortTlso rigidlined cust fab two
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0488
Tlso, triplanar control, one 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
shortTlso rigid lined pre one pie
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0490
Tlso, sagittal-coronal control, one 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
shortTlso rigid plastic pre one
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0491
Tlso, sagittal-coronal 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 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
shortTlso 2 piece rigid shell
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration
L0492
Tlso, sagittal-coronal control, modular segmented spinal system, three 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
shortTlso 3 piece rigid shell
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.02 Date of Service Edit: PolicyAnatomic Consideration
DME1.02 Date of Service Edit: PolicyAnatomic Consideration