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Last Modified: 6/24/2020 Location: FL, PR, USVI Business: Part B

Physicians: Are you ordering a spinal orthosis for your patient?

The durable medical equipment Medicare administrative contractors (DME MACs) are providing helpful guidance to assist the supplier in providing a spinal orthosis to your patient. Medicare coverage requires the patient's medical record to show the orthosis is medically necessary and that there is a valid and complete order for the orthosis.
Coverage criteria documentation requirements
A spinal orthosis (L0450-L0651) is covered when it is ordered for one of the following indications:
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 and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.
The durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier must have a dispensing order prior to providing the orthosis. The supplier may not submit a claim for reimbursement until you sign a detailed written order after this. The detailed written order must contain the elements as described in the local coverage article Standard Documentation Requirements for All Claims Submitted to DME MACs external link.
Help your patient by providing this information in a timely manner.

Documentation requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the beneficiary's medical records will reflect the need for the care provided.
All orders and medical records must meet CMS signature requirements outlined in MLN Matters® (MM) 6698 external pdf file.
For additional information on the coverage and limitations of spinal orthoses, review the Spinal Orthoses: thoracic lumbar sacral orthoses (TLSO) and lumbar sacral orthoses (LSO) local coverage determination (LCD) (L33790 external link) and the LCD-related policy article (A52500 external link).
The spinal orthoses: TLSO and LSO LCD and policy article can also be located at the following:
DME MAC Jurisdiction A external link (CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, District of Columbia)
DME MAC Jurisdiction B external link (IL, IN, KY, MI, MN, OH, WI)
DME MAC Jurisdiction C external link (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
DME MAC Jurisdiction D external link (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.