Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME 12” Abdominal Binder, 4 Panels #232 3-in-1 Ultra Cincher (Style #4000) 9” Abdominal Binder, 3 Panels #219 Abdominal Support Girdle (Model ASG973) Abdominal Support Girdle (Model ASG974 (E)) Abdominal Support Girdle (Model ASG974) Abdominal Support, Postpartum (Model PPG-972) Aspen LSO (Models 990040, 990041, 990060, 990061) (Re-Review) BabyHugger Basic Cincher (Style #5000) Bio Skin Back Skin with Flexible Support Bio Skin Back Skin with Flexible Support and Lumbar Foam Pad Bio Skin Back Skin with Lumbar Foam Pad Bio Skin Back Skin with Lumbar Pocket Bio Skin Back Skin with Thermoplastic Insert Bio Skin Standard Back Skin Bio-Back Bio-Bak
Palmetto GBA - SADMERC
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
A-T Surgical Manufacturing Company, Inc. Christina Studio, Inc. A-T Surgical Manufacturing Company, Inc.
K0634
23-Nov-04
K0634
5-Nov-02
K0634
23-Nov-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0634
25-Oct-04
Aspen Medical Products
K0640
3-Feb-05
Trenna Ventions, Inc. Christina Studio, Inc.
K0630 K0634
5-Feb-03 5-Nov-02
L0500 L0500
Cropper Medical, Inc.
K0634
26-Jun-01
L0500+L0999
Cropper Medical, Inc.
K0634
26-Jun-01
L0500+L0999
Cropper Medical, Inc.
K0635
26-Jun-01
L0500+L0999
Cropper Medical, Inc.
K0634
26-Jun-01
L0500
Cropper Medical, Inc.
K0635
26-Jun-01
L0515
Cropper Medical, Inc. BF Bio-Supports, Inc. BioNamics, Inc.
K0634 K0636 L1499
26-Jun-01 5-Feb-03 17-Jan-96
L0500 L1499
Page 1
L0500
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
HCPCS CODE
EFFECTIVE DATE
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
Boston Brace Body Jacket - Terrapin LSO Boston Brace International, Inc.
K0648
8-Oct-02
L0565
Boston Brace Body Jacket LSO - Custom Boston Brace International, Inc. Made
K0649
8-Oct-02
L0550 or L0560
Boston LS540 Lumbo Sacral Orthosis
Boston Brace International, Inc.
K0639
7-Apr-04
L0515
Boston LS565
Boston Brace International, Inc.
K0642
23-Feb-04
L0565
Boston Soft Corset - BiValve (Model BSC01)
Boston Brace International, Inc.
K0646
23-Nov-04
Boston Transitional Brace (Model BTB01) Boston Brace International, Inc.
K0642
4-May-04
L0561
Cinchim for Men (Style #6000) ComfAlign Female Brace with Ratchet & Ladder ComfAlign Female Brace with Velcro ComfAlign Male Brace with Ratchet & Ladder ComfAlign Male Brace with Velcro Comfortable Lumbo-Sacral Support (Model 03.635) Cool, Lightweight 7” Lumbar Sacral Support (Model 31-701)
Christina Studio, Inc.
K0634
5-Nov-02
L0500
The Bremer Group
K0646
17-Jul-03
L0565
The Bremer Group
K0646
17-Jul-03
L0565
The Bremer Group
K0646
17-Jul-03
L0565
The Bremer Group
K0646
17-Jul-03
L0565
Pantymed Argentina
K0634
23-Oct-03
L0500
FLA Orthopedics, Inc.
K0634
2-Nov-04
PRODUCT NAME
MANUFACTURER
Cybertech 1000
Bio Cybernetics International
K0634
27-Jan-98
Cybertech Body Jacket
Bio Cybernetics International
K0648
5-Oct-04
Cybertech Chairback Bi-Modular System
Bio Cybernetics International
K0642
6-Oct-04
Palmetto GBA - SADMERC
Page 2
L0500 (This product is no longer manufactured by Bio Cybernetics International, effective 7/27/04.)
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME Cybertech MAC (Mechanical Advantage Corset) Cybertech MAS (Mechanical Advantage Spine) Cybertech MAStd (Mechanical Advantage Standard/Lo-Profile) Dale Abdominal Binder (Models H84105251, H84105271, H84104101, H84104111, H84104181, H84108101, H84108111, H84108181, H84108191, H84108201, H84109201) DAS Orthosis (Model 6000) Deluxe Lumbar Support, 11" Height (Model Series 31-101) Deluxe Lumbar Support, 9” Height with Moldable Thermo Insert (Model 31-103) Disc Unloader Orthosis (Models 35-4000, 35-4001, 35-4002, 35-4003, 35-4004) DynaFlex LSO Elastic Abdominal Binder 3 Panel 9” (Model AB-309) Elastic Abdominal Binder 4 panel 12” (Model AB-412) Elastic Abdominal Binder, Universal (Model 34-710UN) Elastic Lumbo-Sacral Support, (Maternity) (Model MS-96) Elastic Lumbo-Sacral Support, (Maternity) (Model MS-99)
Palmetto GBA - SADMERC
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
Bio Cybernetics International
K0634
5-Oct-04
Bio Cybernetics International
K0639
5-Oct-04
Bio Cybernetics International
K0636
6-Oct-04
Dale Medical Products, Inc.
K0634
20-Apr-04
Orthofix Inc.
K0636
19-Apr-04
FLA Orthopedics, Inc.
K0634
8-Jul-04
FLA Orthopedics, Inc.
K0635
23-Nov-04
Corflex, Inc.
K0636
6-Oct-04
Dynamic Bracing of Polk, Inc.
K0649
4-May-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
25-Oct-04
FLA Orthopedics, Inc.
K0634
2-Nov-04
ITA-Med Co.
K0630
20-Oct-04
ITA-Med Co.
K0634
20-Oct-04
Page 3
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
L0560
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
Elastic Sized Abdominal Binder (Model 34510)
FLA Orthopedics, Inc.
K0634
23-Oct-03
L0500
Elcross Lumbar Support Models 132, 133
Camp
K0637
16-Feb-99
L0500
Ongoing Care Solutions, Inc. Ongoing Care Solutions, Inc. Orthofix, Inc.
K0636 K0642 K0639
23-Sep-02 10-Dec-04 1-May-03
L0515
Alex Orthopedic
K0634
2-Nov-04
FLA Orthopedics, Inc.
K0634
23-Oct-03
L0500
Pantymed Argentina
K0637
23-Oct-03
L0500
PMT Corporation
K0648
15-Oct-03
L0565
Christina Studio, Inc. Judah Manufacturing Corporation Judah Manufacturing Corporation Judah Manufacturing Corporation Spinal Technology, Inc.
K0634
5-Nov-02
L0500
K0636
3-Jul-02
L0515+L1499
K0634
3-Jul-02
L0500
K0648
3-Jul-02
L0565
K0648
16-Apr-01
Advanced Orthotic Designs
K0639
30-Jun-04
Advanced Orthotic Designs
K0635
30-Jun-04
E-Z Max LSO E-Z Wear LSO Body Jacket EZBrace LSO Feather Weight Lumbar Belt (Model 2035) Four Panel Surgical Abdominal Binder (Model 34-640) High Lumbo-Sacral Support (Model 03.630) Inflatable Lumbo-Sacral Orthosis (Model 1515) Intimate Cincher (Style #3000) Judah Low-Pro LSO Judah Lumbar Sacral Orthosis – “Judah Belt” Judah Perfect Fit LSO Body Jacket L.S.O. Bi-Valve Lace IT Bi-Powered Low Profile L.S.O. with Dynamically Self-Adjusting Frame (Models 401 S/M/L and 475 SM/LX/XX) Lace IT Bi-Powered Low Profile L.S.O. without Dynamically Self-Adjusting Frame (Models 401 S/M/L)
Palmetto GBA - SADMERC
Page 4
L0515
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME Lace IT Bi-Powered Standard L.S.O. with Dynamically Self-Adjusting Frame (Models 451 S/M/L and 475 SM/LX/XX) Lace IT Bi-Powered Standard L.S.O. without Dynamically Self-Adjusting Frame (Models 451 S/M/L)
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
Advanced Orthotic Designs
K0639
30-Jun-04
Advanced Orthotic Designs
K0635
30-Jun-04
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
A-T Surgical Manufacturing Company, Inc. Star Medical Systems
K0634
23-Nov-04
K0646
9-Jun-04
Star Medical Systems
K0639
7-Apr-04
L0515+L1499
LEEDer Group, Inc.
K0636
6-Aug-03
L0515+L1499
LSO-CF 11-9 Thin, Medium (Re-Review)
LEEDer Group, Inc.
K0636
6-Aug-03
L0515+L1499
LSO-CF 16-9 Padded, Large (Re-Review)
LEEDer Group, Inc.
K0636
6-Aug-03
L0515+L1499
FLA Orthopedics, Inc.
K0634
8-Jul-04
FLA Orthopedics, Inc.
K0634
4-Aug-04
Alex Orthopedic
K0634
2-Nov-04
ITA-Med Co.
K0639
25-Oct-04
Pantymed Argentina
K0634
23-Oct-03
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
25-Oct-04
LSO Back Support #930 LSO Body Jacket (Model #010094) LSO Body Jacket with APL Control (Model 010096) LSO-CF 11-6 Thin, Xtra Small (ReReview)
Lumbar Sacral Support with Overlapping Abdominal Belt, 10" Height (Model Series 31-208) Lumbar Sacral Support, 11" with Flexible Stays (Model 31-550) Lumbar Support with Overlapping Straps (Model 2051) Lumbo-Sacral Orthosis Support (Model LSO-981) Lumbo-Sacral Support (Model 09.F1) Lumbo-Sacral Support, 80% Wool (Model TGR-201) Lumbo-Sacral Support, Elastic (Model IBS2000)
Palmetto GBA - SADMERC
Page 5
L0500
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME Lumbo-Sacral Support, Elastic (Model IBS3000) Lumbo-Sacral Support, Elastic CrissCross (Model BS-220) Lumbo-Sacral Support, Elastic DuoAdjustable (Model BS-227) Lumbo-Sacral Support, Extra Strong 12” (Model LS-112) Lumbo-Sacral Support, Neoprene (Model NWA-152) Lumbo-Sacral Support, w/Pocket for RPP (Model BS-229) Maternity Support Girdle (Models PNG971, PNG-971A) Mesh Industrial Back Support (Model 2099) New Edge Dual LumbLock (Product #580) New Edge Extra LumbLock (Product #575) New Edge LumbLock (Product #570) OPTEC Edge LSO Spinal Management System - Prefabricated OPTEC LSO Anterior Overlap – Custom Fabricated OPTEC LSO BiValve A over P – Custom Fabricated OPTEC LSO BiValve P over A – Custom Fabricated OPTEC Oasis LSO Spinal Management System - Prefabricated
Palmetto GBA - SADMERC
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
20-Oct-04
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0634
26-Oct-04
Alex Orthopedic
K0634
2-Nov-04
M.I.H. International Inc.
K0637
16-Oct-01
L0500
M.I.H. International Inc.
K0637
16-Oct-01
L0500
M.I.H. International Inc.
K0637
16-Oct-01
L0500
OPTEC, Inc.
K0648
9-Jun-04
OPTEC, Inc.
K0649
9-Sep-04
OPTEC, Inc.
K0649
9-Sep-04
OPTEC, Inc.
K0649
9-Sep-04
OPTEC, Inc.
K0646
20-Oct-04
Page 6
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
PRODUCT NAME OPTEC Primo LSO Spinal Management System - Prefabricated Original Cincher (Style #2000) Ortho Cincher Ortholign LSO Modular Spinal System
Ortholign LSO Modular Spinal System – Low Profile OrthoWraps Back and Waist Support – Double Strap Design (#3215) Pro-Fitt L.S.O. (Re-Review) Pro-Fitt T.L.S.O. (LSO) RCAI Lumbar Sacral Orthosis (45LSO) Sacro Back Support #911 SecuTec Dorso Orthotic Sof-Loc Lumbar Sacral Orthosis Soft Form Lumbar Sacral Support, 11” with Contoured Stays (Model Series 31560) Soft Form Posture Control Brace (Model 16-900) Soft Form Thermal Lumbar Support (Model 31-600)
Palmetto GBA - SADMERC
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
OPTEC, Inc.
K0648
6-Oct-04
Christina Studio, Inc. Christina Studio, Inc. DeRoyal - Atlanta International Division (Previously manufactured by Atlanta International) DeRoyal - Atlanta International Division (Previously manufactured by Atlanta International)
K0634 K0639
5-Nov-02 24-Dec-02
L0500 L0515
K0640
4-Apr-02
L0561+L1499
K0640
4-Apr-02
L0561+L1499
SPI Sports/Science, Inc.
K0634
21-Sep-01
L0500
K0648
5-Aug-03
L0565
K0648
8-Jan-01
L0565 + L0999
K0642
10-Nov-99
L0520
K0634
23-Nov-04
K0637
9-Dec-03
L0515
K0635
28-Feb-96
L0515
FLA Orthopedics, Inc.
K0635
4-Dec-02
L0515
FLA Orthopedics, Inc.
K0637
2-Feb-04
L0500
FLA Orthopedics, Inc.
K0634
2-Nov-04
American Professional Bracing, Inc. American Professional Bracing, Inc. RCAI A-T Surgical Manufacturing Company, Inc. Bauerfeind USA, Inc. American Professional Bracing, Inc.
Page 7
Updated: 02/08/05
Lumbar Sacral Orthosis Product Classification List
MANUFACTURER
HCPCS CODE
EFFECTIVE DATE
HCPCS CODE FOR DATES OF SERVICE PRIOR TO 4/1/04
Bauerfeind USA, Inc.
K0646
27-Jul-04
L0565
Bauerfeind USA, Inc.
K0634
1-Jan-02
L0500
Star Medical Systems American Professional Bracing, Inc.
K0637
7-Apr-04
L0515
K0640
2-Jul-03
L0515+L1499
Thermal Lumbar Support (Models 31-750, 31-753)
FLA Orthopedics, Inc.
K0634
2-Nov-04
Thermoskin Back with Elastic Straps #227
United Pacific, Inc.
K0637
10-Aug-98
L0500
Thermoskin Standard Back #213 Thoracic Lumbo-Sacral Orthosis (Model TLSO-250A) Thoracic Lumbo-Sacral Orthosis (Model TLSO-250P) Thoracic Lumbo-Sacral Orthosis, with Moldable Plastic Insert (Model TLSO251A) Three Panel Surgical Abdominal Binder (Model 34-630) USA LSO Brace VertAlign LSO
United Pacific, Inc.
K0637
1-Jan-03
L0500
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0634
25-Oct-04
ITA-Med Co.
K0639
20-Oct-04
FLA Orthopedics, Inc.
K0634
23-Oct-03
L0500
USA Sport & Health The Bremer Group American Professional Bracing, Inc. Meditech Meditech Ziggy's Miracle Brace
K0648 K0648
12-Nov-03 9-Dec-03
L0565 L0565
K0636
28-Feb-96
L0515+L1499
K0639 K0639 K0634
15-Dec-98 15-Dec-98 13-Oct-04
L0515 L0515
PRODUCT NAME SofTec Lumbo, with Plastic Shell and Stays (Re-Review) SofTec Lumbo, with Stays Only (AlphaNumeric Workgroup Review) Star Brace II (Model #010098) System-Loc (3-Piece)
V-Loc Lumbar Sacral Orthosis Yogips Back Brace Yogips Naehury Back Brace Ziggy's Miracle Brace
Palmetto GBA - SADMERC
Page 8
Updated: 02/08/05
