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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:

L0210        Thoracic rib belt
L1800        Knee orthosis, elastic with stays, prefabricated
L1815        Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated
L1825        Knee orthosis, elastic knee cap, prefabricated
L1901        Ankle orthosis, elastic, prefabricated
L3651        Shoulder orthosis, single shoulder, elastic, prefabricated
L3652        Shoulder orthosis, double shoulder, elastic, prefabricated
L3700        Elbow orthosis, elastic with stays, prefabricated
L3701        Elbow orthosis, elastic, prefabricated
L3909        Wrist orthosis, elastic, prefabricated
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:

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
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
L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated
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
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.

These changes will be incorporated in upcoming revisions of the Ankle-Foot/Knee-Ankle-Foot Orthoses, Knee Orthoses, and Spinal Orthoses medical policies.

Date Posted 03/04/09