IMS Experts Partnership with HCA
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Indications for Medical Necessity

Pt requires brace:
⃝     To reduce pain by restricting mobility to the trunk.
⃝     To facilitate healing following an injury to the spine or related soft tissue
⃝     To otherwise support weak spinal muscles OR deformed spine 

 

Clinical Note Requirements: Dictation must be exactly as shown above for the indication chosen.

LSO Brace Indications for Prescribed PT:

(Must select one of the following):

LSO Brace

L0650

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Most common ICD-10 codes:

M54.5 Low back pain

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region

M51.37 Other intervertebral disc degeneration, lumbosacral region

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M54.17 Radiculopathy, lumbosacral region

M48.07 Spinal stenosis, lumbosacral region

LSO Document Requirements: Signed/Dated RX, Clinicals with Indications. Up to date patient demographics with insurance information.

Lumbar Bone Growth Stimulator for Prescribed PT:

(Must select one of the following):
⃝     Failed spinal fusion (ICD-10 code Z98.1) where a minimum of nine months has elapsed since the last surgery.
⃝     Following a multilevel spinal fusion surgery (ICD-10 code Z98.1).
⃝     Following spinal fusion surgery (ICD-10 code Z98.1) where there is a history of a previously failed spinal fusion at the same site.

 

Clinical Requirements: Must be Multi-Level Fusion. No single level fusion approvals. 

Lumbar Bone Growth Stimulator

E0748

Most common ICD-10 codes:

Z98.1- Arthrodesis status

M54.5 Low back pain

M51.16 Intervertebral disc disorders with radiculopathy, lumbar region

M51.37 Other intervertebral disc degeneration, lumbosacral region

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

M54.17 Radiculopathy, lumbosacral region

M48.07 Spinal stenosis, lumbosacral region

Bone Growth Stimulator Document Requirements: Signed/Dated RX, Clinicals with Indications. Signed/Dated CMN. Up to date patient demographics with insurance information.