CurrentCapital BluecrossPolicy MP 6.063

SPINAL ORTHOSES (OTHER THAN FOR SCOLIOSIS)

Defines medical necessity criteria, applicable codes and diagnoses, and billing guidance for prefabricated and custom thoracic-lumbar-sacral (TLSO), lumbar-sacral (LSO) and lumbar orthoses for Capital Blue Cross products (excluding scoliosis-specific braces). Applies to certain programs/products and is subject to benefit variations.

Policy Summary

PayerCapital Bluecross

PolicySPINAL ORTHOSES (OTHER THAN FOR SCOLIOSIS)

Policy CodePolicy MP 6.063

Change TypeMinor review; consensus review

Effective Date1/1/2026

Next Review Date

Key ActionProvider requesting/ordering the DME should have an established relationship with the member and be involved in the ongoing care of the member and the condition for which the orthotic is prescribed.

POLICY UPDATE CHANGES

11/05/2024 Minor Review: Updated language from NMN to INV if criteria is not met for prefabricated and custom TLSO, LSO and lumbar orthoses.

07/21/2025 Consensus Review: No changes to policy statements. Coding updated and no changes.

63+Applicable ICD-10 diagnosis codes listed

50+Listed HCPCS L-codes

1Policy number

Coverage Summary

Medical Necessity Criteria

Medically necessary indications

The use of prefabricated TLSO, LSO and lumbar orthoses may be considered medically necessary when ANY of the following are met:

ANY of the following

To reduce pain by restricting mobility of the trunk.
To facilitate healing following an injury to the spine or related soft tissues.
To facilitate healing following a surgical procedure on the spine or related soft tissue.
To otherwise support weak spinal muscles.

ref": "b1_0

title": "Medically necessary indications

Additional criteria for custom-fitted and custom-fabricated back braces

Custom-fitted/custom-fabricated braces require ALL of the following:

ALL of the following

There is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
The brace is the initial one issued after surgical stabilization of the spine following traumatic injury.
custom brace can be initial post-op brace after traumatic surgical stabilization

ref": "b1_1

title": "Additional criteria for custom-fitted and custom-fabricated back braces

Not medically necessary / investigational

If the criteria above are not met, THEN:

ALL of the following

Both prefabricated and custom TLSO, LSO and lumbar orthoses will be denied as investigational due to insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

ref": "b1_2

title": "Not medically necessary / investigational

Operational notes

ALL of the following

Post-operative back braces are considered part of the surgical protocol for certain back operations.
May be included in surgical package; coverage subject to benefit terms.
Provider requesting/ordering the DME should be a provider with whom the member has an established relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.

ref":

Definitions and Background

Spinal orthoses are classified as prefabricated (including preformed), custom‑fitted, or custom‑fabricated (molded-to-individual). They control trunk and intersegmental vertebral motion in the sagittal, coronal/frontal and transverse planes (sagittal control via a rigid posterior panel; coronal control via mid‑axillary rigid panels; transverse control via sternal or anterior chest panels or rigid extensions). Examples of prefabricated devices include lumbosacral corsets, Knight spinal braces, and the CASH brace; preformed (stock) orthoses such as the Milwaukee, Boston, Charleston and Wilmington braces are also considered prefabricated. Custom‑fitting involves trimming, bending, or molding a prefabricated shell after measuring the patient; custom fabrication involves individually making an orthosis from basic materials (vacuum forming, molding, sewing) or from an impression/positive model. Note: scoliosis‑specific braces are excluded from this policy scope.

References supporting the policy include professional society guidelines (AANS/CNS), randomized controlled trials, systematic reviews and other clinical studies evaluating brace therapy, postoperative corset use, and orthosis efficacy and fabrication methods.

Prefabricated orthosis: Manufactured in quantity without a specific individual in mind; may include preformed shells; may be trimmed/adjusted for fit; assembled from prefabricated components is considered prefabricated.

Custom‑fitted orthosis: A prefabricated orthosis that has been trimmed, bent, molded or otherwise modified for use by a trained professional after taking body measurements.

Custom‑fabricated (molded‑to‑individual) orthosis: Individually made for a specific individual by a trained professional starting with basic materials and involving substantial work (vacuum forming, molding, sewing) or made from an impression/positive model of the patient.

Coding

Covered HCPCS procedure codes (when medically necessary)HCPCSCovered

L0452
L0454
L0455
L0456
L0457
L0458
L0460
L0462
L0464
L0466

1–10 of 58

1/6

Applicable diagnosis codes for reimbursementICD-10Covered

A18.01	Tuberculosis of spine
G90.1	Familial dysautonomia [Riley-Day]
M08.1	Juvenile ankylosing spondylitis
M25.78	Osteophyte, vertebrae
M40.03	Postural kyphosis, cervicothoracic region
M40.04	Postural kyphosis, thoracic region
M40.05	Postural kyphosis, thoracolumbar region
M40.13	Other secondary kyphosis, cervicothoracic region
M40.14	Other secondary kyphosis, thoracic region
M40.15	Other secondary kyphosis, thoracolumbar region

1–10 of 262

1/27

Billing Rule

Coverage dependent on benefit terms — verify member benefit and reimbursement eligibility

Identification of a code in the coding section does not denote coverage; coverage is determined by the member’s benefit information. Not all covered services are eligible for separate reimbursement. Verify the member’s benefit plan and eligibility for reimbursement before billing.

Provider Actions & Documentation Requirements

Documentation Required

Prescribing provider relationship — documentation requirement

The prescribing/provider ordering the durable medical equipment (DME) must have an established relationship with the member and be involved in the ongoing care of the member and the condition for which the orthotic is prescribed. This relationship and involvement are required for the request/order.

Denial Risk

Denial risk if criteria unmet — investigational/Not medically necessary

If the policy criteria for medical necessity are not met, both prefabricated and custom TLSO, LSO and lumbar orthoses will be denied as investigational due to insufficient evidence to support general health outcomes or benefits. Requests that do not satisfy the listed medically necessary indications (or additional criteria for custom braces) carry a high risk of denial.

Operational note: Post‑operative back braces may be considered part of the surgical protocol for certain spine operations and therefore may be included in the surgical package; coverage and separate reimbursement remain subject to member benefit terms. The provider ordering the DME should have an established relationship with the member and be involved in the ongoing care of the condition for which the orthotic is prescribed.

Policy Summary

PayerCapital Bluecross

PolicySPINAL ORTHOSES (OTHER THAN FOR SCOLIOSIS)

Policy CodePolicy MP 6.063

Change TypeMinor review; consensus review

Effective Date1/1/2026

Next Review Date

On This Page

OpenPayer

SPINAL ORTHOSES (OTHER THAN FOR SCOLIOSIS)

Coverage Summary

Medical Necessity Criteria

Definitions and Background

Coding

Provider Actions & Documentation Requirements

Revision History