Spinal Orthosis (TLSO/LSO)

Coverage Determination:

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



  • Product Description: Pre-Fabricated LSO
  • Product Treats: Spinal Stenosis, Compression Fracture, Discogenic Disease, Osteoporosis, Osteoarthritis, Scoliosis, Kyphosis, Lumbosacral Spondylosis, Prolapse of Disc, Disorders of Sacrum, Pain in Thoracic Spine, Pain in Lumbar Spine
  • Product Utilization: Patient has one of the conditions listed above and requires a back brace
  • Sizes: Short-Tall, X-Slim-X-Full, based on measurement around fullest part of hips
  • Coding: LSO- L0631. ICD: 724.02 Spinal Stenosis, 353.1 Compression Fracture, 722.2 Discogenic Disease, 733.0 Osteoporosis, 721.90 Osteoarthritis, 721.3 Lumbosacral Spondylosis, 722.2 Prolapse of Disc, 724.6 Disorders of Sacrum, 737.30 Scoliosis, 737.9 Kyphosis, Pain in Lumbar Spine 724.2, Pain in Thoracic Spine 724.1
  • Required Documentation: Therapy, Nursing or Physician notes stating the patient has one of the above conditions and requires a back brace. Telephone order is required stating one of the above listed conditions. Adjunct Products: Shoulder straps to enhance posture

OrthoPro Lumbar Sacral Orthosis (LSO)

OrthoPro Lumbar Sacral Orthosis

  • Product Description: Lumbar Sacral Orthosis
  • Product Treats: Displacement of lumbar disc, lumbar sacral instability or inflammation, spondylosis and spinal degeneration
  • Product Utilization: Bend to fit better for optimal fit and comfort
  • Sizes: Small, medium or large based on midriff circumference
  • Coding: L0627 sagitt rigit panel. ICD codes 724.02, 722.20, 721.90 724.60 - all related to curvature of the spine and disc disorders
  • Required Documentation: Therapy, Nursing or Physician notes stating the patient has the above diagnosis and requires a LSO for treatment of curvature of the spine or spinal disc disorders. Telephone order is required for dispensing stating the diagnosis above.
  • Adjunct Products: Also comes in hard shell for additional support creating more support for post-surgical disorders, L0639. Can also be ordered with cervical flexion addition for head support and or eating assistance. This is non-billable and limited success. Requires management approval prior to order.