Medical Policy

Effective Date:06/01/2017 Title:Back Braces
Revision Date:01/01/2020 Document:BI534:00
CPT Code(s):L0220, L0450, L0452, L0454, L0455-L0625, L0626, L0627, L0628-L0629, L0630, L0631-L0651, L0700-L0710, L0970-L0976, L0978, L0980, L0982, L0984, L0999, L1000, L1001, L1005, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499, 63003, 63005, 63011, 63012, 63016, 63017, 63030, 63035, 63042, 63044, 63046-63048, 63085-63088, 63090, 63091, 63101-63103, 63170, 63172, 63173, 63185, 63190, 63191, 63195, 63197, 63199, 63200, 63251, 63252, 63266-63268, 63271-63273, 63276-63278, 63281-63283, 63286, 63287, 63290, 63295, 63301-63303, 63305-63308, 97760, 97762, 97763
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    “Orthotic devices” and “orthotic services” are covered for QualChoice’s fully-insured plans in compliance with Arkansas law (Arkansas Code Annotated § 23-99-403 et seq. See Background for details of the Law) and as reflected in your Certificate of Coverage or Evidence of Coverage and Benefits Summary. Per Arkansas law, “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet criteria for orthotics and are therefore not covered.

2)    All codes listed in this medical policy are not necessarily covered services. Please see details under the “Medical Policy Statement” section for coverage of specific services. HCPC codes for back braces that are not specified under the medical policy statement are not considered medically necessary and are therefore not covered.

 

3)    QualChoice does not cover replacement of an orthotic device or associated orthotic services more frequently than one (1) time every three (3) years unless medically necessary or indicated by other coverage criteria under the QualChoice fully-insured plan. However, QualChoice will replace the orthotic if necessary due to anatomical changes or normal use.  Replacement will be made based on necessity due to normal use if: (a) the orthotic has been rendered unusable, (b) the damage was not caused by neglect or misuse, (c) the cost of repair exceeds the replacement cost, and (d) the orthotic is not currently covered by warranty. The replacement of an orthotic device is subject to co-payments, deductibles, and co-insurance, as set out in your Benefits Summary.

4)    Back braces are generally not covered unless there is documentation of spinal stenosis, certain types of scoliosis, acute fracture of the spine or recovery following spinal surgery. In these situations, only specific types of back braces (as outlined in the medical policy statement) are covered. Evidence does not support the use of back braces for chronic back pain.

Medical Statement

As defined by Arkansas law (Arkansas Code Annotated § 23-99-403 et seq. see Background for details of the Law) and covered under QualChoice’s fully-insured plans, the brace must meet all of the following three (3) requirements for an orthotic device:

1)    The external device is:

a)    Intended to restore physiological function or cosmesis to a patient; AND

b)    Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with the delivery of the device to the patient.

2)    The device must be prescribed by one of the following:

                                          i.    A licensed doctor of medicine,

                                        ii.    A licensed doctor of osteopathy,

                                       iii.    A licensed doctor of podiatric medicine.

3)    The device must be provided by one of the following:

                                          i.    A licensed doctor of medicine,

                                        ii.    A licensed doctor of osteopathy,

                                       iii.    A licensed doctor of podiatric medicine,

                                       iv.    A licensed orthotist,

                                        v.     A licensed prosthetist.

In accordance with the above definition, any brace or support intended to enhance function past normal, such as back braces intended to prevent injury or to permit especially heavy lifting, are not considered an orthotic device, and are not covered. QualChoice only covers selected back braces based on medical necessity and cost effectiveness.

I. The following back braces are covered without preauthorization as outlined below:

A) Rib belt (L0220) with diagnosis of rib fracture(s) (S22.000A – S22.9XXS)

B) Sacral and Thoracic/Lumbar/Sacral Orthotics (L0450, L0454, L0626, L0627 &  

     L0630) with a diagnosis of:

·         Spinal stenosis (M48.04, M48.05, M48.06, M48.061, M48.062, M48.07, M48.08);

·         Thoracic vertebral fractures (S22.000A – S22.089S);

·         Lumbar vertebral fractures  (S32.000A – S32.059S);

·         Sacral fractures (S32.10XA – S32.19XS);

·         Lumbar spondylolisthesis (M43.16);  

·         Osteomyelitis of lumbar vertebra (M46.26);

·         Lumbar discitis (M46.46);

·         Lumbar spine instability (M53.2X6); 

·         Subluxation lumbar spine (M99.13);

·         Lumbar surgeries: fusion of spine thoracolumbar region (M43.25), lumbar spinal fusion (M43.26), post laminectomy syndrome (M96.3), post-laminectomy lordosis (M96.4) with any diagnosis, and other post-procedural state, lumbar discectomy, lumbar laminectomy (Z98.89);

·         Any diagnosis code if requested within 10 days post-op for a thoracic and/or lumbar spinal surgery:

    63003 – 63012, 63016 – 63017, 63030 – 63035, 63042, 63044,

63046 – 63048, 63085 – 63091, 63101 – 63103, 63170 – 63173,

63185 – 63191, 63195, 63197, 63199 – 63200, 63251 – 63252,

63266 – 63268, 63271 – 63273, 63276 – 63278, 63281 – 63283,

63286 – 63295, 63301 – 63303, 63305 – 63308.

C)  Scoliosis Orthotics (L1000 – L1290) with a diagnosis of:

·         Infantile idiopathic scoliosis, cervicothoracic-lumbosacral (M41.03 – M41.07);

·         Juvenile scoliosis, cervicothoracic-lumbosacral (M41.113 – M41.117);

·         Adolescent scoliosis, cervicothoracic-lumbosacral (M41.123 – M41.127);

·         Idiopathic scoliosis, cervicothoracic-lumbosacral (M41.23 – M41.27);

·         Thoracogenic scoliosis (M41.34 – M41.35);

·         Neuromuscular cervicothoracic-lumbosacral (M41.43 – M41.47);

·         Other secondary scoliosis, cervicothoracic-lumbosacral (M41.53 – M41.57);

·         Other forms of scoliosis, cervicothoracic-lumbosacral (M41.83 – M41.87);

·         Orthotic management/training (97760, 97763)

 

Codes Used In This BI:

L0220 Thoracic, rib belt, custom fabricated L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks w/rigid stays or panel(s), incl shoulder straps & closures, prefab, off-the-shelf L0452 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks w/rigid stays or panel(s), incl shoulder straps & closures, custom fab L0454 TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T–9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks w/rigid stays or panel(s), incl shoulder straps & closures, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0455 TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T–9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks w/rigid stays or panel(s), incl shoulder straps & closures, prefab, off-the-shelf L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the saggital plane, produces intracavitary pressure to reduce load on the intervertebral disks, incl straps & closures, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0457 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the saggital plane, produces intracavitary pressure to reduce load on the intervertebral disks, incl straps & closures, prefab, off-the-shelf L0458 TLSO, triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab, incl fitting & adjustment L0460 TLSO, triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0462 TLSO, triplanar control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab, incl fitting & adjustment L0464 TLSO, triplanar control, modular segmented spinal system, 4 rigid plastic shells, posterior extends from sacrococcygeal junction & terminates just inferior to scapulas spine, anterior extends from symphsis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab, incl fitting & adjust L0466 TLSO, sagittal control, rigid posterior frame & flexible soft anterior apron w/straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by an indiv w/expertise L0467 TLSO, saggital control, rigid posterior frame & flexible soft anterior apron w/straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefab, off-the-shelf L0468 TLSO, saggital-coronal control, rigid posterior frame & flexible soft anterior apron w/straps, closures & padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefab item that has been trimmed, bent, molded, assembled, or othrewise customized to fit a spec pt by an indiv w/expertise L0469 TLSO, saggital-coronal control, rigid posterior frame & flexible soft anterior apron w/straps, closures & padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefab, off-the-shelf L0470 TLSO, triplanar control, rigid posterior frame & flexible soft anterior apron w/straps, closures & padding, extends from sacrococcygeal junction to scapulae, lateral strength provided by pelvic, thoracic, & lateral frame pieces, rotation strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal & transverse planes, incl fitting & shaping the frame, prefab, incl fitting & adjust L0472 TLSO, triplanar control, hyperextension, rigid anterior & lateral extends frm symphysis pubis to sternal notch w/2 anterior components (1 pubic & 1 sternal), posterior & lateral pads w/straps & closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal & transverse planes, incl fitting & shaping the frame, prefab, incl fitting & adjust L0480 TLSO, triplanar control, 1 piece rigid plastic shell w/out interface liner, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, & transverse planes, incl a carved plaster or CAD-CAM model, custom fab L0482 TLSO, triplanar control, 1 piece rigid plastic shell w/interface liner, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, & transverse planes, incl a carved plaster or CAD-CAM model, custom fab L0484 TLSO, triplanar control, 2 piece rigid plastic shell w/out interface liner, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in sagittal, coronal, & transverse planes, incl a carved plaster or CAD-CAM model, custom fab L0486 TLSO, triplanar control, 2 piece rigid plastic shell w/interface liner, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in sagittal, coronal, & transverse planes, incl a carved plaster or CAD-CAM model, custom fab L0488 TLSO, triplanar control, 1 piece rigid plastic shell w/interface liner, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, & transverse planes, prefab, incl fitting & adjustment L0490 TLSO, sagittal-coronal control, 1 piece rigid plastic shell w/overlapping reinforced anterior, w/mult straps & closures, posterior extends frm sacrococcygeal junction & terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xyphoid, anterior opening, restricts gross trunk motion in sagittal & coronal planes, prefab, incl fitting & adjustment L0491 TLSO, sagittal-coronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends frm sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from symphysis pubis to xyphoid, soft liner, restricts gross trunk motion in sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab, incl fitting & adjustment L0492 TLSO, sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends frm sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from symphysis pubis to xyphoid, soft liner, restricts gross trunk motion in sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, incl straps & closures, prefab, incl fitting & adjustment L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion abt the sacroiliac joint, incl straps, closures, may incl pendulous abdomen design, prefab, off-the-shelf L0622 Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion abt the sacroiliac joint, incl straps, closures, may incl pendulous abdomen design, custom fab L0623 Sacroiliac orthosis, provides pelvic-sacral support, w/rigid or semi-rigid panels over the sacrum & abdomen, reduces motion about the sacroiliac joint, incl straps, closures, may incl pendulous abdomen design, prefab, off-the-shelf L0624 Sacroiliac orthosis, provides pelvic-sacral support, w/rigid or semi-rigid panels placed over the sacrum & abdomen, reduces motion about the sacroiliac joint, incl straps, closures, may incl pendulous abdomen design, custom fab L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends frm L-1 below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may incl pendulous abdomen design, shoulder straps, stays, prefab, off-the-shelf L0626 Lumbar orthosis, sagittal control, w/rigid posterior panel(s), posterior extends from L–1 to below L–5 vertebra, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0627 Lumbar orthosis, sagittal control, w/rigid anterior & posterior panels, posterior extends from L–1 to below L–5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may incl padding, shoulder straps, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends frm sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0629 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends frm sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0630 Lumbar-sacral orthotic, sagittal control, w/rigid posterior panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0631 Lumbar-sacral orthotic, sagittal control, w/rigid posterior panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0632 Lumbar-sacral orthotic, sagittal control, w/rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fab L0633 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0634 Lumbar-sacral orthotic, sagittal-coronal control, w/rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fab L0635 Lumbar-sacral orthotic, sagittal-coronal control, lumbar flexion, w/rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, anterior panel, pendulous abdomen design, prefab, incl fitting & adjustment L0636 Lumbar-sacral orthotic, sagittal-coronal control, lumbar flexion, w/rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fab L0637 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0638 Lumbar-sacral orthotic, sagittal-coronal control, w/rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fab L0639 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, incl straps, closures, may include soft interface, pendulous abdomen design, prefab item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a spec pt by indiv w/expertise L0640 Lumbar-sacral orthotic, sagittal-coronal control, w/rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, incl straps, closures, may include soft interface, pendulous abdomen design, custom fab L0641 Lumbar orthosis, sagittal control, w/rigid posterior panel(s), posterior extends from L–1 to below L–5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0642 Lumbar orthosis, sagittal control, w/rigid anterior & posterior panel(s), posterior extends from L–1 to below L–5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0643 Lumbar-sacral orthosis, sagittal control, w/rigid posterior panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0648 Lumbar-sacral orthosis, sagittal control, w/rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0649 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0650 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, incl straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefab, off-the-shelf L0651 Lumbar-sacral orthosis, sagittal-coronal control, w/rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T–9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strangth is provided by overlapping rigid material & stabilizing closures, incl straps, closures, may include soft interface, pendulous abdomen design, prefab, off-the-shelf L0700 CTLSO, anterior-posterior-lateral control, molded to patient model, Minerva type L0710 CTLSO, anterior-posterior-lateral control, molded to patient model, w/interface material, Minerva type L0970 TLSO, corset front L0972 LSO, corset front L0974 TLSO, full corset L0976 LSO, full corset L0978 Axillary crutch extension L0980 Peroneal straps, prefab, off-the-shelf, pair L0982 Stocking supporter grips, prefab, off-the-shelf, set of 4 L0984 Protective body stock, prefab, off-the-shelf, each L0999 Addition to spinal orthotic, NOS L1000 CTLSO (Milwaukee), incl of furnishing initial orthotic, incl model L1001 CTLSO, immobilizer, infant size, prefab, incl fitting, & adjustment L1005 Tension based scoliosis orthotic & accessory pads, incl fitting, & adjustment L1010 Addtn to CTLSO or scoliosis orthotic, axilla sling L1020 Addtn to CTLSO or scoliosis orthotic, kyphosis pad L1025 Addtn to CTLSO or scoliosis orthotic, kyphosis pad, floating L1030 Addtn to CTLSO or scoliosis orthotic, lumbar bolster pad L1040 Addtn to CTLSO or scoliosis orthotic, lumbar or lumbar rib pad L1050 Addtn to CTLSO or scoliosis orthotic, sternal pad L1060 Addtn to CTLSO or scoliosis orthotic, thoracic pad L1070 Addtn to CTLSO or scoliosis orthotic, trapezius sling L1080 Addtn to CTLSO or scoliosis orthotic, outrigger L1085 Addtn to CTLSO or scoliosis orthotic, outrigger, bilateral w/vertical extensions L1090 Addtn to CTLSO or scoliosis orthotic, lumbar sling L1100 Addtn to CTLSO or scoliosis orthotic, ring flange, plastic or leather L1110 Addtn to CTLSO or scoliosis orthotic, ring flange, plastic or leather, molded to patient model L1120 Addtn to CTLSO or scoliosis orthotic, cover for upright, each L1200 Addtn to TLSO, incl of furnishing initial orthotic only L1210 Addtn to TLSO, (low profile), lateral thoracic extension L1220 Addtn to TLSO, (low profile), anterior thoracic extension L1230 Addtn to TLSO, (low profile), Milwaukee type superstructure L1240 Addtn to TLSO, (low profile), lumbar derotation pad L1250 Addtn to TLSO, (low profile), anterior asis pad L1260 Addtn to TLSO, (low profile), anterior thoracic derotation pad L1270 Addtn to TLSO, (low profile), abdominal pad L1280 Addtn to TLSO, (low profile), rib gusset (elastic), each L1290 Addtn to TLSO, (low profile), lateral trochanteric pad L1300 Other scoliosis procedure, body jacket molded to patient model L1310 Other scoliosis procedure, postop body jacket L1499 Spinal orthotic, NOS 63003 Laminectomy w/explortn and/or dcmprsn of spinal cord and/or cauda equina, w/o facetectomy, foraminotomy or discectomy, 1 or 2 vrtbrl sgmnts; thoracic 63005 lumbar, except for spondylolisthesis 63011 sacral 63012 Laminectomy w/remvl of abnrml facets and/or pars inter-articularis w/dcmprsn of cauda equina & nerve roots for spondylolisthesis, lumbar 63016 Laminectomy w/explortn/dcmprsn of spinal cord/cauda equina, w/o facetectomy, foraminotomy or discectomy, more than 2 vrtbrl sgmnts; thoracic 63017 lumbar 63030 Laminotomy, w/dcmprsn of nerve root(s), incl prtl facetectomy, foraminotomy/excision of herniated intrvrtbrl disc; 1 interspace, lumbar + 63035 ea addtl interspace, cervical or lumbar (add-on code) 63042 Laminotomy, w/dcmprsn of nerve root(s), incl prtl facetectomy, foraminotomy and/or excision of herniated intrvrtbrl disc, re-exploration, sgl interspace; lumbar + 63044 ea addtl lumbar interspace (add-on code) 63046 Laminectomy, facetectomy & foraminotomy, sgl vrtbrl sgmt; thoracic 63047 lumbar + 63048 ea addtl sgmt, cervical, thoracic, or lumbar (add-on code) 63085 Vertebral corpectomy, prtl or cmplt, transthoracic approach w/ dcmprsn of spinal cord/nerve root(s); thoracic, sgl sgmt 63086 thoracic, ea addtl sgmt (add-on code) 63087 Vertebral corpectomy, prtl or cmplt, combined thoracolumbar approach w/dcmprsn of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; sgl sgmt 63088 ea addtl sgmt (add-on code) 63090 Vertebral corpectomy, prtl or cmplt, transperitoneal or retroperitoneal approach w/dcmprsn of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; sgl sgmt 63091 ea addtl sgmt (add-on code) 63101 Vertebral corpectomy, prtl or cmplt, lateral extracavitary approach w/dcmprsn of spinal cord/nerve root(s); thoracic, sngl sgmt 63102 lumbar; sgl sgmt + 63103 thoracic or lumbar, ea addtl sgmt (add-on code) 63170 Laminectomy w/myelotomy, cervical, thoracic, or thoracolumbar 63172 Laminectomy w/drainage of intramedullary cyst/syrinx; to subarachnoid space 63173 to peritoneal or pleural space 63185 Laminectomy w/rhizotomy; 1 or 2 sgmts 63190 more than 2 sgmts 63191 Laminectomy w/section of spinal accessory nerve 63195 Laminectomy w/cordotomy, w/sectn of 1 spinothalamic tract, 1 stage, thoracic 63197 Laminectomy w/cordotomy, w/sectn of both spinothalamic tracts, 1 stage, thoracic 63199 Laminectomy w/cordotomy, w/sectn of both spinothalamic tracts, 2 stages within 14 days; thoracic 63200 Laminectomy, w/release of tethered spinal cord, lumbar 63251 Laminectomy for excsn /occlsn of arterioven malfrmtn of spinal cord; thoracic 63252 thoracolumbar 63266 Laminectomy for excsn/evacuat of intraspnl lesn othr than neopl, extrdrl; thoracic 63267 lumbar 63268 sacral 63271 Laminectomy for excsn of intraspnl lesn othr than neopl, intrdrl; thoracic 63272 lumbar 63273 sacral 63276 Laminectomy for biopsy/excsn of intrspnl neopl; extrdrl, thoracic 63277 extrdrl, lumbar 63278 extrdrl, sacral 63281 intrdrl, extramedullary, thoracic 63282 intrdrl, extramedullary, lumbar 63283 intrdrl, sacral 63286 intrdrl, intramedullary, thoracic 63287 intrdrl, intramedullary, thoracolumbar 63290 combined extrdrl-intrdrl lesion, any level + 63295 Osteoplastic recnstrctn of dorsal spnl elmnts, follow prim intrspnl proc (add-on code) 63301 Vertebral corpectomy, prtl or cmplt, for excisn of intrspnl lesn, sgl sgmt; extrdrl, thoracic by transthoracic approach 63302 extrdrl, thoracic by thoracolumbar approach 63303 extrdrl, lumbar or sacral by transperitoneal or retroperitoneal approach 63305 intrdrl, thoracic by transthoracic approach 63306 intrdrl, thoracic by thoracolumbar approach 63307 intrdrl, lumbar or sacral by transperitoneal or retroperitoneal approach + 63308 ea addtl sgmt (add-on code) 97760 Orthotic management & training, each 15 mins 97763 Checkout orthotic/prosthetic use established patient, each 15 mins
Limits

1)    Back Braces codes that are not specified in the medical policy statement are not covered.

2)    No appliance or device will be covered as an orthotic device and no service will be covered as an orthotic service if it does not meet the definitions of orthotic device and orthotic service under Arkansas law and as set forth in the Background statement of this policy.

3)    Services or equipment that is more costly are not covered when QualChoice determines that less costly, equally effective services or equipment is available.

4)    Materials or services covered under a manufacturer’s warranty are not covered.

5)    Procedures, services, or supplies rendered in the course of providing a non-covered service are not covered.

Reference

1)    Arkansas Code Annotated § 23-99-403 et seq.

2)    Williams KD. Fractures, dislocations, and fracture-dislocations of the spine. In: Canale ST, Beaty JH, editors. Campbell`s Operative Orthopedics. 12th ed. Philadelphia, PA: Elsevier Mosby; 2013:1559-628.

3)    Chang V, Holly LT. Bracing for thoracolumbar fractures. Neurosurgical Focus 2014; 37(1):E3. DOI: 10.3171/2014.4.FOCUS1477.

4)    Bakhsheshian J, Dahdaleh NS, Fakurnejad S, Scheer JK, Smith ZA. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of non-operative management. Neurosurgical Focus 2014; 37(1):E1. DOI: 10.3171/2014.4.FOCUS14159

5)    Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. New England Journal of Medicine 2013; 368(9):834-41. DOI: 10.1056/NEJMcp1209063.

6)    Altaf F, Gibson A, Dannawi Z, Noordeen H. Adolescent idiopathic scoliosis. British Medical Journal 2013; 346:f2508.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.