Modifier CG

Policy criteria applied

Spinal Garments

The CG modifier must be added to the following spinal garments made primarily of non-elastic material (e.g., canvas, cotton or nylon) or has a rigid posterior panel:

  • L0450 - TLSO, flexible, provides trunk support, upper thoracic region
  • L0454 - TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra
  • L0621 - Sacroiliac Orthosis, flexible
  • L0625 - Lumbar orthosis, flexible, provides lumbar support
  • L0628 - Lumbar-sacral orthosis, flexible provides lumbo-sacral support

Therapeutic Continuous Glucose Monitoring Devices

For therapeutic CGM devices (codes E2102 or E2103) and the supply allowance (codes A4238 or A4239) only, the CG modifier must be added to the claim line only if all of the therapeutic CGM coverage criteria (1-5) in the Glucose Monitor Local Coverage Determination are met.

 

Last Updated May 01 , 2023