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Linda Collins Blogger

Medically Necessary Criteria for Spinal Braces - old

Posted by Linda Collins | November 15, 2016

​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 various types of braces.

Spinal Orthoses: TLSO and LSO (L0450 - L0651)

According to this LCD, 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.

The physician's medical records must have sufficient documentation to support one or more of the above criteria.

Many spinal orthoses have mirror codes, meaning the brace can be billed as "off the shelf" or "custom fit". Custom fit orthoses are identified as those products requiring substantial modification at time of fitting. The modifications must be documented, in detail, in the patient's medical records. Substantial modifications are those beyond what the beneficiary could perform at home, such as a simple adjustment or tightening a strap.

As a reminder, Medicare does not allow templates or checklists as documentation.

PDAC Verification

In order to bill spinal braces to Medicare, there must be coding verification by the Pricing, Data Analysis, and Coding (PDAC) contractor. You do not need a copy of the actual PDAC Coding Verification letter from the manufacturer, but you do need to verify the listing on

Delivering in Hospital or SNF

If a spinal orthosis is delivered to a beneficiary in a hospital or SNF for use during the inpatient stay (e.g. for use after surgery and/or as part of the inpatient rehabilitation protocol), Medicare's payment to the facility covers the cost of the brace. You will not receive payment on a claim submitted in this situation.

The only exception to this rule is when the brace is delivered to the beneficiary in the hospital, within 48 hours of discharge, and is intended for use at home. All the medical necessity criteria for the use of the spinal orthosis must be documented.

Additional information about billing may be found in the Össur Reimbursement Guide for Spinal Bracing, which is available from your Össur Rep. The entire Spinal Orthoses LCD may be downloaded on the DME MAC sites. 

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]