HCPCS Code L0628

Official Description

Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Short Descr	Lso flex no ri stays pre ots
Coverage	Carrier Priced
Pricing Indicator(s)	38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings)
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	D1F – Prosthetic/Orthotic devices
TOS Code(s)	P – Lump sum purchase of DME, prosthetics, orthotics
Added Date	1/1/2006
APC Status Indicator	Service Paid under Fee Schedule or Payment System other than OPPS
MUE	0
MUE	1
OTS Orthotic	Yes
CCS Clinical Classification	243 - DME and supplies

GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GP	Services delivered under an outpatient physical therapy plan of care
CG	Policy criteria applied
GX	Notice of liability issued, voluntary under payer policy
GA	Waiver of liability statement issued as required by payer policy, individual case
J4	Dmepos item subject to dmepos competitive bidding program that is furnished by a hospital upon discharge
KT	Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
KX	Requirements specified in the medical policy have been met
LT	Left side (used to identify procedures performed on the left side of the body)
NU	New equipment
ST	Related to trauma or injury