L0455 — Tlso, flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk 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, off-the-shelf
HCPCS Level II L-code · short descriptor: “Tlso flex trnk sj-t9 pre ots”
- Code system
- HCPCS Level II
- Family
- L — Orthotics & prosthetics
- Medicare coverage status
- Carrier judgment — coverage decided by the DME MAC
- DMEPOS payment category
- Prosthetics & orthotics
- Prior authorization
- Not on Medicare required-PA list
- Face-to-face & WOPD
- Not on the required list
- MUE unit limit
- 1
- Status
- Active (HCPCS Level II October 2026)
Prior authorization
Not on the Medicare required-PA list (CMS Required Prior Authorization List — 74 items in force on 2026-10-25; 8 more from 2026-10-28; sources: CMS list updated 2026-01-13, CMS-6109-N (91 FR 47972)). Medicare Advantage and commercial plans set their own prior-authorization rules for this code — verify per plan before delivery.
Order readiness — what the written order must contain
Every Medicare DMEPOS claim needs a Standard Written Order with all six elements (42 CFR 410.38(d)):
- Beneficiary name or Medicare Beneficiary Identifier (MBI) (42 CFR 410.38(d)(1)(i)(A))
- General description of the item (42 CFR 410.38(d)(1)(i)(B))
- Quantity to be dispensed, if applicable (42 CFR 410.38(d)(1)(i)(C))
- Order date (42 CFR 410.38(d)(1)(i)(D))
- Treating practitioner name or NPI (42 CFR 410.38(d)(1)(i)(E))
- Treating practitioner signature (42 CFR 410.38(d)(1)(i)(F))
Not on the F2F/WOPD list (CMS Required F2F & WOPD List — 83 items in force on 2026-10-25; 22 more from 2026-10-28; sources: CMS list effective 2026-04-13 (91 FR 1250), CMS-6109-N (91 FR 47972)). The standard written order must reach the supplier before claim submission.
Blank requirements checklist only — MyMedi-AI never collects or stores completed orders.
L0455 Medicare fee schedule (October 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $118.65 to $417.25 depending on state and rural status.
| State | Non-rural | Rural |
|---|---|---|
| AK | $396.43 | — |
| AL | $269.37 | $348.95 |
| AR | $269.37 | $348.93 |
| AZ | $254.02 | $342.69 |
| CA | $118.65 | $342.69 |
| CO | $176.82 | $350.13 |
| CT | $269.37 | $342.69 |
| DC | $236.34 | $342.69 |
| DE | $236.34 | $342.69 |
| FL | $269.37 | $348.95 |
| GA | $269.37 | $348.95 |
| HI | $396.43 | — |
| IA | $264.08 | $346.75 |
| ID | $176.82 | $342.69 |
| IL | $228.66 | $347.79 |
| IN | $228.66 | $347.79 |
| KS | $264.08 | $346.75 |
| KY | $269.37 | $348.95 |
| LA | $269.37 | $348.93 |
| MA | $269.37 | $342.69 |
| MD | $236.34 | $342.69 |
| ME | $269.37 | $342.69 |
| MI | $228.66 | $347.79 |
| MN | $264.08 | $347.79 |
| MO | $264.08 | $346.75 |
| MS | $269.37 | $348.95 |
| MT | $176.82 | $350.13 |
| NC | $269.37 | $348.95 |
| ND | $264.08 | $350.13 |
| NE | $264.08 | $346.75 |
| NH | $269.37 | $342.69 |
| NJ | $236.34 | $342.69 |
| NM | $254.02 | $348.93 |
| NV | $118.65 | $342.69 |
| NY | $236.34 | $342.69 |
| OH | $228.66 | $347.79 |
| OK | $254.02 | $348.93 |
| OR | $118.65 | $342.69 |
| PA | $236.34 | $342.69 |
| PR | $417.25 | — |
| RI | $269.37 | $342.69 |
| SC | $269.37 | $348.95 |
| SD | $264.08 | $350.13 |
| TN | $269.37 | $348.95 |
| TX | $254.02 | $348.93 |
| UT | $176.82 | $350.13 |
| VA | $269.37 | $342.69 |
| VI | $417.25 | — |
| VT | $269.37 | $342.69 |
| WA | $118.65 | $342.69 |
| WI | $228.66 | $347.79 |
| WV | $269.37 | $342.69 |
| WY | $176.82 | $350.13 |
Unit limit (MUE)
Medicare's Medically Unlikely Edit caps L0455 at 1 unit per date of service (absolute). Units above the MUE deny — typically as CO-151. Rationale: Anatomic Consideration.
Common denial codes to watch
Related L-codes
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