HCPCS Code L0633

Official Description

Lumbar-sacral orthosis, sagittal-coronal control, with 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 intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Short Descr	Lso sc r pos/lat pnl pre cst
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

CG	Policy criteria applied
GA	Waiver of liability statement issued as required by payer policy, individual case
GL	Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
KX	Requirements specified in the medical policy have been met
NU	New equipment