Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 19003 | Noridian Healthcare Solutions, LLC | DME MAC | AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY |
| 18003 | CGS Administrators, LLC | DME MAC | AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV |
| 17013 | CGS Administrators, LLC | DME MAC | IL IN KY MI MN OH WI |
| 16013 | Noridian Healthcare Solutions, LLC | DME MAC | CT DC DE MA MD ME NH NJ NY PA RI VT |
Procedure codes named in the LCD
A4467 (Belt, Strap, Sleeve, Garment, Or Covering, Any Type), A9270 (Non-Covered Item Or Service), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), L0622 (Sacroiliac Orthosis, Flexible, Provides Pelvic-Sacral Support, Reduces Motion About The Sacroiliac Joint, Includes Straps, Closures, May Include Pendulous Abdomen Design, Custom Fabricated), 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), 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), L0625 (Lumbar Orthosis, Flexible, Provides Lumbar Support, Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Pendulous Abdomen Design, Shoulder Straps, Stays, Prefabricated, Off-The-Shelf), L0626 (Lumbar Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From L-1 To Below L-5 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), L0627 (Lumbar Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From L-1 To Below L-5 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), 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), L0641 (Lumbar Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Stays, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf), L0642 (Lumbar Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf), L0643 (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, Off-The-Shelf), L0648 (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, Off-The-Shelf), L0649 (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, Off-The-Shelf), L0650 (Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And 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, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf), L0651 (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, Off-The-Shelf), L0980 (Peroneal Straps, Prefabricated, Off-The-Shelf, Pair), L0982 (Stocking Supporter Grips, Prefabricated, Off-The-Shelf, Set Of Four (4)), L0984 (Protective Body Sock, Prefabricated, Off-The-Shelf, Each), L4002 (Replacement Strap, Any Orthosis, Includes All Components, Any Length, Any Type).
Coverage indications, limitations and medical necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• Refer to the Supplier Manual for additional information on documentation requirements.
• Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the "reasonable and necessary" criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
For spinal orthoses definitions of Off-The-Shelf (OTS), custom fitted and custom fabricated, refer to the CODING GUIDELINES section in the LCD-related Policy Article.
A spinal orthosis (L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651) is covered when it is ordered for one of the following indications:
• To reduce pain by restricting mobility of the trunk; or
• To facilitate healing following an injury to the spine or related soft tissues; or
• To facilitate healing following a surgical procedure on the spine or related soft tissue; or
• 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.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2020-01-01
- Last reviewed by the contractor
- 2019-01-08
- MCD version
- 20
- Derived from
- L27017
Other related documents: A52500 (Article), A55426 (Article).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.
Frequently asked questions
What does LCD L33790 cover?
For spinal orthoses definitions of Off-The-Shelf (OTS), custom fitted and custom fabricated, refer to the CODING GUIDELINES section in the LCD-related Policy Article. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33790 apply to?
Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33790?
The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.
How do I appeal a denial under LCD L33790?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.