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Linda Collins Blogger

Medically Necessary Criteria for Spinal Braces

Posted by Linda Collins | May 09, 2017

In order for an item to be considered for coverage by Medicare, it must be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…" The Local Coverage Determination (LCDs) give detailed information about medical necessity requirements for Spinal Orthoses.

Spinal Orthoses: TLSO and LSO (L0450 - L0651)

According to the LCD (L33790), spinal orthoses are covered for patients when the brace is prescribed to:

  • Reduce pain by restricting mobility of the trunk; OR
  • Facilitate healing following an injury to the spine or related tissue; OR
  • Otherwise support weak and/or deformed spinal muscles.

Documentation in the supplier's medical records and the prescribing physician's medical records must support the medical necessity of the brace with details on one of the above conditions. Additional information needed in the documentation includes:

  • Identifying patient information
  • Patient's diagnosis
  • Duration of patient's condition
  • Clinical course
  • Prognosis
  • Nature and extent of functional limitations
  • Other therapeutic interventions and results

ICD 10 Diagnosis Codes

The Medicare LCD and most private payers do not list specific ICD-10 codes associated with a spinal orthoses. These policies usually state that the brace must be used to restrict pain, facilitate healing or support a weak body part. Your documentation will be important in determining the medical necessity of the brace.

Additional Documentation

A detailed written order (DWO) must be received before a claim is submitted.

A proof of delivery (POD) is are required for all dispensed orthotics, including spinal braces. Proof of delivery documentation must be made available to the Medicare contractor upon request.

More information about Spinal Orthoses coding requirements can be found in the LCD (L33790) and the Policy Article (A55426.) Sample medical record notes are available in the Össur Reimbursement Guide for Spinal Orthoses.

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