Browse HCPCS Level II 2020 Edition

HCPCS Level II Table of Contents

L0628 - L0640  Lumbar-Sacral Orthotics

L0628
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
shortLso flex no ri stays 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
L0629
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
shortLso flex w/rigid stays cust
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
L0630
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
shortLso r post pnl 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
L0631
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
shortLso sag r an/pos pnl 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
L0632
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
shortLso sag rigid frame cust
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
L0633
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
shortLso sc r pos/lat pnl 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
L0634
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
shortLso flexion control 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
L0635
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
shortLso sagit rigid panel prefab
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
L0636
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
shortLso sagittal rigid panel cus
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
L0637
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
shortLso sc r ant/pos pnl 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
L0638
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
shortLso sag-coronal 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
L0639
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
shortLso s/c shell/panel prefab
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
L0640
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
shortLso s/c shell/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