Medical policy: Spinal Orthoses (Other than for Scoliosis)

Número de política: MP 6.063

Fecha de entrada en vigor: 11/1/2026

Política

The use of prefabricated thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO) and lumbar orthoses may be considered medically necessary when any of the following conditions are met:

• 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

The following additional criteria apply to custom-fitted and custom-fabricated back braces.

• There is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
• The brace is the initial one issued after surgical stabilization of the spine following traumatic injury.

If the criteria above are not met; both prefabricated and custom TLSO, LSO and lumbar orthoses will be denied as investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Note: Post-operative back braces are considered part of the surgical protocol for certain back operations.

The provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Refer to Section VI of the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Descripción/Antecedentes

A spinal orthosis can be designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one of more planes of motion: lateral/flexion (side bending) in the coronal/frontal plane, anterior flexion (forward bending) or posterior extension (backward bending) in the sagittal plane, and axial rotation (twisting) in the transverse plane. Each type of movement is controlled by a placement of specific types of brace sections:

• Sagittal control is achieved by a rigid posterior panel.
• Coronal/frontal control is achieved by a rigid panel in the mid-axillary line which is either an integral part of a posterior or anterior panel or a separate panel.
• Transverse control is achieved by one of several possible structural features:
  • A rigid panel in the upper sternal area which is an integral part of an anterior shell; or
  • A rigid panel in the upper sternal area which is rigidly attached to rigid abdominal or posterior panel; or
  • Rigid extensions from a rigid posterior panel to the upper anterior chest bilaterally.

A prefabricated orthosis is one which is manufactured in quantity without a specific individual in mind. Prefabricated spinal braces may not require the placement or adjustment by a trained orthotist. Examples of prefabricated orthoses include lumbosacral corsets, Knight spinal braces, and the CASH (cruciform anterior spinal hyperextension) brace.

A custom fitted orthosis is a particular type of prefabricated orthosis which is manufactured in quantity without a specific individual in mind, typically as a plastic torso shell, which has been trimmed, bent, molded (with or without heat), or otherwise modified for use by an appropriate licensed and trained medical professional subsequent to the taking of appropriate body measurements. An orthosis that is assembled from prefabricated components is considered prefabricated.

A preformed orthosis is considered prefabricated even if it requires the attachment of straps and/or the addition of a lining and/or other finishing work. Multiple measurements of the body part may be taken to determine which stock size of a prefabricated orthosis will provide the best fit. An orthosis that is assembled from prefabricated components is considered prefabricated. Examples include the Milwaukee scoliosis brace, the Boston scoliosis brace, the Charleston scoliosis brace, and the Wilmington brace. Any orthosis that does not meet the definition of a custom fabricated orthosis is considered prefabricated.

A custom fabricated or custom molded orthosis is one which is individually made for a specific individual by a trained medical professional starting with basic materials including, but not limited to plastic, metal, leather, or cloth. It involves substantial work such as vacuum forming, cutting, molding, sewing, etc. It involves more than trimming, bending, or making other modifications to a substantially prefabricated plastic shell. A molded-to-individual orthosis is a specific type of custom fabricated or molded orthosis in which an impression of the specific body part is made by a trained medical professional using one of several methods, including plaster casting, anthropometric measurements, or computerized modeling. These methods are all used to create a model of the individual that is used to make a positive model of the body part being fitted with an orthosis. This positive model is used to custom fit a prefabricated orthosis.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas pólizas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: esta lista de códigos puede no ser exhaustiva y los códigos están sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Cubierto cuando es médicamente necesario

Referencias

1. Resnick DK, Choudhri TF, Dailey AT, et al.; American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14: brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine. 2005;2(6):716-724.
2. Yee AJ, Yoo JU, Marsolais EB, et al. Use of a postoperative lumbar corset after lumbar spinal arthrodesis for degenerative conditions of the spine. A prospective randomized trial. J Bone Joint Surg Am. 2008; 90(10):2062-2068. doi:10.2106/JBJS.G.01093
3. Lang G, Hirschmüller A, Patermann S, et al.. Efficacy of Thoracolumbar Bracing in Spinal Immobilization: Precise Assessment of Gross, Intersegmental, and Segmental Spinal Motion Restriction by a 3D Kinematic System. World neurosurgery. 2018;1:116:e128-46. doi:10.1016/j.wneu.2018.04.133
4. Urquhart JC, Osama A. Alrehaili OA, et al. Treatment of thoracolumbar burst fractures: extended follow-up of a randomized clinical trial comparing orthosis versus no orthosis. J Neurosurg Spine. 2017; Jul 1;27(1):42-7. doi:10.3171/2016.11.SPINE161031
5. Turner MS, Carus DA, Troup IM; Custom moulded plastic spinal orthoses. Prosthetics and orthotics international. 1986;10(2), 83-88.
6. Pergolizzi JV Jr, LeQuang JA. Rehabilitation for Low Back Pain: A Narrative Review for Managing Pain and Improving Function in Acute and Chronic Conditions. Pain Ther. 2020;9(1):83-96. doi:10.1007/s40122-020-00149-5
7. McAviney J, Mee J, Fazalbhoy A, Du Plessis J, Brown BT. A systematic literature review of spinal brace/orthosis treatment for adults with scoliosis between 1967 and 2018: clinical outcomes and harms data. BMC musculoskeletal disorders. 2020;21(1):87
8. Kreiner, S., & Matz, P. (2020). Spine. Evidence Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain.
9. Herget GW, Patermann S, Strohm PC, et al. Spinal Orthoses: The Crucial Role of Comfort on Compliance of Wearing - Monocentric Prospective Pilot Study of Randomized Cross-Over Design. Acta Chir Orthop Traumatol Cech. 2017;84(2):91-96.