Browse HCPCS Level II 2020 Edition

HCPCS Level II Table of Contents

L0621 - L0624  Orthotic Devices - Sacroilliac, Lumbar, Sacral Orthosis

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
shortSio flex pelvic/sacr 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
L0622
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
shortSio flex pelvisacral custom
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
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
shortSio rig pnl pelv/sac 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
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
shortSio panel custom
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