Last Modified: 9/20/2023
Location: FL, PR, USVI
Business: Part B
Revised January 11
The durable medical equipment (DME) MACs are providing helpful guidance to assist the supplier in providing a spinal orthosis to your patient. Medicare must be able to verify that there is supporting medical record documentation for the provision of a spinal orthosis for 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 supplier must have a standard written order (SWO) prior to submitting a claim to Medicare or a written order prior to delivery (WOPD) and face-to-face encounter for items on the required-face-face-encounter-and-written-order-prior-delivery-list.pdf (cms.gov)
. The SWO must contain the elements listed below. Assist your patient by providing the order and documentation to substantiate need in a timely manner. In addition to the "reasonable and necessary" criteria outlined in the LCD, there are further payment rules related to documentation requirements. For details related to those documentation requirements, review the policy article for standard documentation requirements for all claims submitted to DME MACs (A55426
An order must contain the following elements to be considered a valis SWO:
• Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
• The description can be either a general description (e.g., spinal orthoses), a HCPCS code, a HCPCS code narrative, or a brand name/model number
• For equipment- In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately)
• For supplies- In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner’s signature
Medicare requires that all HCPCS codes that appear on the required prior authorization list
must be submitted for prior authorization before delivery and claim submission.
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
For additional information on the coverage and limitations of spinal orthoses, review the Spinal orthoses: TLSO and LSO LCD (L33790
) and the LCD-related policy article (A52500
Help your patient by providing this information in a timely manner.
Additional information is located on the DME MAC contractor websites:
• DME MAC Jurisdiction A
(CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, District of Columbia)
• DME MAC Jurisdiction C
(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
(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.