|
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
| short | Tlso flex trunk/thor pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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|
|
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
| short | Tlso flex custom fab thoraci |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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|
|
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
| short | Tlso trnk sj-t9 pre cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso flex trnk sj-t9 pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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|
|
|
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
| short | Tlso flex trnk sj-ss pre cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso flex trnk sj-ss pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso 2mod symphis-xipho pre |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso 2 shl symphys-stern cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso 3mod sacro-scap pre |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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|
|
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
| short | Tlso 4mod sacro-scap pre |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso r fram soft ant pre cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso r fram soft pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rig fram pelvic pre cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rig fram pelvic pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid frame pre subclav |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid frame hyperex pre |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid plastic custom fa |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid lined custom fab |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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|
|
|
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
| short | Tlso rigid plastic cust fab |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigidlined cust fab two |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid lined pre one pie |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso rigid plastic pre one |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso 2 piece rigid shell |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic 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
| short | Tlso 3 piece rigid shell |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 1.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|