September 18, 2026

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are providing helpful guidance to assist the supplier in providing a spinal orthosis to your patient. Medicare must be able to verify the medical record supports your patient's need for a spinal orthosis.

Medicare coverage requires that the patient's medical record shows the orthosis is medically necessary and that there is a valid and complete order for the orthosis.

Coverage Criteria Documentation Requirements

A spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following indications:

• 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.

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.

The supplier must have a Standard Written Order (SWO) before submitting a claim to Medicare or Written Order Prior to Delivery (WOPD) before providing the item. Items on the required Face-Face (F2F) Encounter and WOPD list require both a WOPD and F2F encounter. The SWO or WOPD must have the elements listed below.

Standard Written Order (SWO)/Written Order Prior to Delivery (WOPD) Elements

An order must contain the following elements:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (such as a spinal orthoses), a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • For equipment - In addition to the description of the base item, the order may include all ordered options, accessories or additional features that are separately billed or require an upgraded code. List each separately.
  • For supplies - In addition to the description of the base item, the DMEPOS order may include all ordered supplies that are separately billed. List each separately.
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

Documentation Requirements

FACE-TO-FACE ENCOUNTER

As a condition of payment, items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List require that a treating practitioner have a face-to-face encounter with their patient within 6 months before the order date.

The face-to-face encounter must support payment for the items ordered and be documented in the medical record. This documentation may include the history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information. The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.

This face-to-face requirement also includes examinations conducted via the CMS-approved use of telehealth examinations, which must meet the requirements of 42 CFR §§ 410.78 and 414.65 for purposes of DMEPOS coverage.

The WOPD must be completed within 6 months after the required face-to-face encounter.

Medicare requires that all HCPCS codes on the Required Prior Authorization List be submitted for prior authorization before delivery and claim submission.

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the beneficiary's medical records will reflect the need for the care provided. All orders and medical records must meet CMS Signature Requirements.

For additional information on the coverage and limitations of spinal orthoses, review the Spinal Orthoses: TLSO and LSO Local Coverage Determination (LCD) (L33790) and the LCD-related Policy Article (A52500).

Help your patient by providing this information in a timely manner.

Additional information is located on the DME MAC contractor websites:

• Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia)
• Jurisdiction B (IL, IN, KY, MI, MN, OH, WI)
• Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
• Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)