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Medically Necessary Criteria for Spinal Bracing - Old

Posted by Linda Collins | May 14, 2015

​Medically Necessary Criteria for Spinal Braces

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

In order to bill TLSO and LSO products to Medicare, there must be a written coding verification by the Pricing, Data Analysis, and Coding (PDAC) contractor (see Products Requiring PDAC Coding Verification.) 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
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. The supplier will not receive additional payment if a claim is submitted in this situation.
The only exception to this rule is when the spinal orthosis 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 Spinal Orthosis billing may be found in the Ossur Reimbursement Guide for Spinal Bracing
The entire LCD may be downloaded on the DME MAC sites listed below:

Region A:
Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont
Region B:
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin
Region C:
Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia.
Region D:
Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming
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]