LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2009-04 Effective: CMS: some elastic garments do not meet the statutory definition

NHIC, Corp.
DME MAC A ListServe For Immediate Release

January 26, 2009

Elastic Garments – Noncovered
  • CMS has determined that elastic garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Therefore, effective for claims with dates of service on or after April 1, 2009, these items will be denied as noncovered, no benefit category.
  • This determination applies to the following HCPCS codes:
  1. L0210 Thoracic rib belt
  2. L1800 Knee orthosis, elastic with stays, prefabricated
  3. L1815 Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated
  4. L1825 Knee orthosis, elastic knee cap, prefabricated
  5. L1901 Ankle orthosis, elastic, prefabricated
  6. L3651 Shoulder orthosis, single shoulder, elastic, prefabricated
  7. L3652 Shoulder orthosis, double shoulder, elastic, prefabricated
  8. L3700 Elbow orthosis, elastic with stays, prefabricated
  9. L3701 Elbow orthosis, elastic, prefabricated
  10. L3909 Wrist orthosis, elastic, prefabricated
  11. L3911 Wrist hand finger orthosis, elastic, prefabricated
  • This determination also applies to elastic spinal garments. Currently, both elastic spinal garments and nonelastic spinal orthoses are billed using the same HCPCS codes. The applicable codes are:
  1. L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated
  1. L0454 TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated
  1. L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated
  1. L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated
  1. L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated
  • Elastic garments may be made of a variety of materials, including but not limited to neoprene or spandex (elastane, Lycra™). They are considered to be elastic even if they have flexible plastic or metal stays. If a garment made with elastic material has a rigid plastic or metal posterior panel, it is considered a nonelastic spinal orthoses for purposes of coverage and coding. A garment that is made primarily of nonelastic material such as cotton or nylon is considered a nonelastic spinal orthosis.
  • Effective for claims with dates of service on or after April 1, 2009, if a spinal garment billed with one of the preceding HCPCS codes is made primarily of elastic material, the supplier must add the GY modifier to the code and the claim line will be denied as noncovered, no benefit category. If a spinal garment billed with one of the preceding codes is made primarily of nonelastic material (e.g., cotton or nylon) or has a rigid posterior panel, the supplier must add the CG modifier (policy criteria applied) to the code. If the CG or GY modifier is not used with one of the preceding HCPCS codes, it will be rejected/denied as incorrect coding. (Note: The CG and GY modifiers are not used with the rib belts or extremity elastic garments discussed in the first section of this article.)
  • Information concerning the correct coding of items may be found in the DMECS Product Classification Lists on the Pricing, Data Analysis, and Coding (PDAC) contractor web site or by contacting the PDAC.
  • These changes will be incorporated in upcoming revisions of the Ankle-Foot/Knee-Ankle-Foot Orthoses, Knee Orthoses, and Spinal Orthoses medical policies.

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