Does L0457 require prior authorization?

Yes, L0457 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`L0457`, Tlso, flexible, provides trunk support, thoracic region, rigid posterior panel

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before claim submission for items addressed in this policy.
For DMEPOS base items that require WOPD, the supplier must have received a signed Written Order Prior to Delivery (WOPD) before delivering the DMEPOS item.
For base items with separately billed options/accessories/supplies, the WOPD must list the base item and may list associated separately billed items prior to delivery.

Suppliers must follow the LCD-related Standard Documentation Requirements Article, the LCD-related Policy Article, the Supplier Manual, and relevant DME MAC web site bulletins for additional documentation and payment rules.

Key Coverage Criteria

Spinal orthoses (listed HCPCS codes) are covered when ordered to reduce pain by restricting mobility of the trunk.
Spinal orthoses are covered when ordered to facilitate healing after an injury to the spine or related soft tissues.
Spinal orthoses are covered when ordered to facilitate healing following a surgical procedure on the spine or related soft tissue.
Spinal orthoses are covered when ordered to support weak spinal muscles and/or a deformed spine.
An item is covered only if it meets Medicare prerequisites: is in a defined Medicare benefit category, is reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meets other applicable Medicare statutory and regulatory requirements.
The use ofprefabricatedthoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is consideredmedically necessarywhenanyof the following conditions are met:

4 Active Policies

ANTHEM-CG-DME-11, CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33790, Spinal Orthoses: TLSO and LSO

AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines

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L0457, Tlso, flexible, provides trunk support, thoracic region, rigid posterior panel