Anthem Blue Cross Connecticut CG-OR-PR-06 Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar Form

This document addresses the use of thoracic-lumbar-sacral (TLSO), lumbar-sacral (LSO), and lumbar spinal orthoses. These types of devices are back braces, which are used for many different purposes, including the treatment of spinal column deformities, trauma, and back pain due to a variety of etiologies. This document addresses the use of back braces that are designed to immobilize or support various levels of the spine to treat back conditions.

Note: For information regarding the use of self-operated spinal unloading devices, including, but not limited to, gravity-dependent and pneumatic devices for the treatment of back pain, please see:

• DME.00025 Self-Operated Spinal Unloading Devices

Clinical Indications

Medically Necessary:

The use of prefabricated thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses is considered medically necessary when any of the following conditions are met:

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

Custom fitted prefabricated spinal orthoses are considered medically necessary for the following indications:

1. Any of the conditions listed above for prefabricated devices; and
2. The treatment of spinal deformity, including but not limited to scoliosis and kyphosis.

Custom fabricated or custom molded spinal orthoses are considered medically necessary when all the criteria below are met:

1. The brace is prescribed for the treatment of a spinal deformity in a skeletally immature individual (for example, scoliosis); and
2. The criteria above for custom fitted devices have been met; and
3. The individual has an underlying deformity or body somatotype which would preclude the use of a prefabricated device.

Not Medically Necessary:

The use of any type of thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) or lumbar orthoses is considered not medically necessary when the medical necessity criteria above have not been met, including but not limited to all other conditions.

An upgrade would be considered a deluxe Durable Medical Equipment (DME) item and considered not medically necessary when its primary purpose is to allow the individual to perform leisure or recreational activities or includes comfort, luxury, or convenience features, or a feature which exceeds that which is considered medically necessary to treat the individual’s condition.