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RX, Pre-Auth & Medical Necessity Certification for LO, LSO, TLSO Braces
EXPECTED BENEFITS OF/NEED FOR LSO/TLSO (check all appropriate):
 Reduce pain by restricting mobility of the trunk
 Facilitate healing following a surgical procedure to the spine
or related soft tissues
DIAGNOSIS
 724.2 Low Back Pain
 728.85 Muscle Spasm
 728.4 Ligamentous Instability
 781.92 Abnormal Posture
 724.4 Lumbar/Thoracic neuritis/radiculitis
 Other:
 Facilitate healing following injury to the spine or related soft
tissues
 Support weak spinal muscles and/or deformed spine
 738.4 Spondylolisthesis
 724.3 Sciatica
 724.9 Nerve Root Compression
 722.10 Disc Displacement w/o myelo
 722.73 Disc Displacement w/ myelo
722.52 Lumbar Disc Degeneration
847.2 Lumbar Sprain/Strain
737.10 Kyphosis
724.1 Pain in Thoracic Spine
724.01 Spinal Stenosis Thoracic
PRESCRIPTION
 CUSTOM-FITTED /PRE-FABRICATED DEVICE REQUIRING SUBSTANTIAL MODIFICATIONS BY AN INDIVIDUAL WITH EXPERTISE AND SPECIALIZED
1,3
TRAINING
TLSO flex trunk thoracic rig P soft A, prefab cust fit
TLSO triplanar, mod segmnt 4 rig shells prefab
TLSO sagit rigid P frame flex A apron prefab cust fit
TLSO triplanr hyprext rig A-L fram prefab cust fit
TLSO sagit-coronal mod segmnt 2 rigid shells prefab
LO sagit rigid P panels prefab cust fit
 OFF-THE-SHELF (OTS)
 L0457
 L0467
 L0625
 L0641
 L0642
 L0627
 L0630
 L0631
 L0633
 L0637
 L0639
LO sagit rigid A-P panels prefab cust fit
LSO sagit rigid P panels prefab cust fit
LSO sagit rigid A-P panels prefab cust fit
LSO sagit-coronal rigid P panel prefab cust fit
LSO sagit-coronal rigid A-P panels prefab cust fit
LSO sagit-coronal rigid panels prefab cust fit
2,3
DEVICE DELIVERED WITH MINIMAL SELF-ADJUSTMENT
TLSO flex trunk thoracic rig P soft A prefab ots
TLSO sagit rigid P frame flex A apron prefab ots
LO flex lumbar spt intracavity pressure prefab ots
LO sagit rigid P panels prefab ots
LO sagit rigid A-P panels prefab ots
 L0643
 L0648
 L0649
 L0650
 L0651
LSO sagit rigid P panels prefab ots
LSO sagit rigid A-P panels prefab ots
LSO sagit-coronal rigid P frame prefab ots
LSO sagit-coronal rigid A-P fr/panels prefab ots
LSO sagit-coronal rigid panels prefab ots
 NEED FOR CUSTOM-FITTING
 Waist to hip ratio/disparity
 Pendulous abdomen
 Obesity
 Short stature/torso
 Hyper/hypo-lordosis
 Multi-vertebral level injury/surgery
 Accommodate post-surgical dressings
 Scoliosis
 Spinal deformity
 Compromised cognitive/physical ability
 Hyper-kyphosis
 Other: _______________________________________________________________________________________
Additional notes:
Duration of need: (
Prognosis:
)Months (
)Years  Life
Frequency of use:  ___/times per day  ___/hours  ___/minutes
 Fair  Good  Excellent
Utilizing accepted medical practice standards; the above-prescribed durable medical equipment is both reasonable and necessary and
essential in the continuous treatment of the patient.
Signature & Credential:
Printed Name:
Date:
NPI:
Patient
Name: ____________________________________ DOB: __________ ID #: ______________ Date: ____ / ____/ ____
© 2014 Otto Bock HealthCare LP ● 80SpineLOMN.10092014
 L0456
 L0464
 L0466
 L0472
 L0491
 L0626
* Definitions for Customization:
1
Substantial Modification*
Substantial modification is defined as changes made to achieve an individualized fit of the
item that requires the expertise of a certified orthotist or an individual who has equivalent
specialized training in the provision of orthotics such as a physician, treating practitioner,
an occupational therapist, or physical therapist in compliance with all applicable Federal
and State licensure and regulatory requirements. A certified orthotist is defined as an
individual who is certified by the American Board for Certification in Orthotics and
Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.
2
Minimal Self Adjustment
The term “minimal self-adjustment” is defined at 42 CFR §414.402 as an adjustment the
beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that
does not require the services of a certified orthotist (that is, an individual who is certified
by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the board
for Orthotist/Prosthetist Certification) or an individual who has specialized training. For
example, adjustment of straps and closures, bending or trimming for final fit or comfort
(not all-inclusive) fall into this category.
3
Reference
Medicare Pricing, Data Analysis and Coding (PDAC). Announcements: PDAC Process to
re-classify orthotic products as Off-The-Shelf. Accessed on October 9, 2014 at
https://www.dmepdac.com/
*

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