Spinal Orthoses LCD

What You Need to Know:

The first part of the LCD is the Coverage Guidance section. Most of it is boilerplate language that appears in every LCD, no matter what the device/item. However, there are a few key points in this section that are important for you to know:

• It includes a list of additional documents that contain other payment rules. This includes the frequently-overlooked Policy Article accompanying the LCD. The Policy Article for spinal orthoses contains important and detailed information about several topics not directly covered in the LCD. (We will cover the Policy Article at the end of this series.)
• It states four central coverage requirements that are unique to spinal orthoses. The device must: (1) reduce pain by restricting trunk mobility, or (2) facilitate healing following an injury to the spine or related soft tissue, or (3) facilitate healing following a surgical procedure on the spine or related soft tissue; or (4) otherwise support weak spinal muscles and/or a deformed spine.

What This Means for You:

First, make sure that you read and understand not only the LCD, but the Policy Article that accompanies it. To find the Policy Article, scroll down to the bottom of the LCD and find the “Associated Documents” section, which has a direct link to the Policy Article.

Second, the four coverage requirements listed at the end of this section are not optional. Your records must demonstrate how the prescribed spinal brace satisfies at least one of those four requirements for you to comply with the LCD. Make sure that you therefore incorporate language addressing one or more of these points into your medical records for every claim. If you are an O&P or DME company, you must additionally confirm that the physician corroborates your assessment in her documentation.

Next in this series: the “General” section (SWO’s, WOPD’s, and POD’s).