L0458 — Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
HCPCS Level II L-code · short descriptor: “Tlso 2mod symphis-xipho pre”
- 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
- Status
- Active (April 2026 HCPCS)
Prior authorization
Not on the Medicare required-PA list as of the January 13, 2026 update (74 items). Medicare Advantage and commercial plans set their own prior-authorization rules for this code — verify per plan before delivery.
L0458 Medicare fee schedule (April 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $1069.75 to $1176.76 depending on state and rural status.
Former-CBA payment limits: ceiling $1305.49 · floor $979.12
| State | Non-rural | Rural |
|---|---|---|
| AK | $1069.75 | — |
| AL | $1101.98 | — |
| AR | $1101.88 | — |
| AZ | $1069.75 | — |
| CA | $1069.75 | — |
| CO | $1108.06 | — |
| CT | $1069.75 | — |
| DC | $1069.75 | — |
| DE | $1069.75 | — |
| FL | $1101.98 | — |
| GA | $1101.98 | — |
| HI | $1069.75 | — |
| IA | $1090.65 | — |
| ID | $1069.75 | — |
| IL | $1096.06 | — |
| IN | $1096.06 | — |
| KS | $1090.65 | — |
| KY | $1101.98 | — |
| LA | $1101.88 | — |
| MA | $1069.75 | — |
| MD | $1069.75 | — |
| ME | $1069.75 | — |
| MI | $1096.06 | — |
| MN | $1096.06 | — |
| MO | $1090.65 | — |
| MS | $1101.98 | — |
| MT | $1108.06 | — |
| NC | $1101.98 | — |
| ND | $1108.06 | — |
| NE | $1090.65 | — |
| NH | $1069.75 | — |
| NJ | $1069.75 | — |
| NM | $1101.88 | — |
| NV | $1069.75 | — |
| NY | $1069.75 | — |
| OH | $1096.06 | — |
| OK | $1101.88 | — |
| OR | $1069.75 | — |
| PA | $1069.75 | — |
| PR | $1176.76 | — |
| RI | $1069.75 | — |
| SC | $1101.98 | — |
| SD | $1108.06 | — |
| TN | $1101.98 | — |
| TX | $1101.88 | — |
| UT | $1108.06 | — |
| VA | $1069.75 | — |
| VI | $1176.76 | — |
| VT | $1069.75 | — |
| WA | $1069.75 | — |
| WI | $1096.06 | — |
| WV | $1069.75 | — |
| WY | $1108.06 | — |
Amounts are the Medicare DMEPOS fee-schedule allowables effective April 2026.
Medicare typically pays 80% of the allowable after the Part B deductible; the patient owes 20%.
A 2% sequestration reduction applies to the Medicare share. Former competitive-bidding-area
adjustments and non-continental rates can differ — verify with your DME MAC.
Common denial codes to watch
Related L-codes
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