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 discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

HCPCS Level II L-code · short descriptor: “Lso flex no ri stays 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
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.

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 (April 13, 2026 update — 83 items). The standard written order must reach the supplier before claim submission.

Blank requirements checklist only — MyMedi-AI never collects or stores completed orders.

L0628 Medicare fee schedule (April 2026)

Base (no modifier) Prosthetics & orthotics

Medicare allowable ranges from $28.70 to $100.92 depending on state and rural status.

State	Non-rural	Rural
AK	$95.91	—
AL	$65.17	$84.39
AR	$65.17	$84.39
AZ	$61.45	$82.90
CA	$28.70	$82.90
CO	$42.78	$84.79
CT	$65.17	$82.90
DC	$57.18	$82.90
DE	$57.18	$82.90
FL	$65.17	$84.39
GA	$65.17	$84.39
HI	$95.91	—
IA	$63.89	$83.88
ID	$42.78	$82.90
IL	$55.32	$84.12
IN	$55.32	$84.12
KS	$63.89	$83.88
KY	$65.17	$84.39
LA	$65.17	$84.39
MA	$65.17	$82.90
MD	$57.18	$82.90
ME	$65.17	$82.90
MI	$55.32	$84.12
MN	$63.89	$84.12
MO	$63.89	$83.88
MS	$65.17	$84.39
MT	$42.78	$84.79
NC	$65.17	$84.39
ND	$63.89	$84.79
NE	$63.89	$83.88
NH	$65.17	$82.90
NJ	$57.18	$82.90
NM	$61.45	$84.39
NV	$28.70	$82.90
NY	$57.18	$82.90
OH	$55.32	$84.12
OK	$61.45	$84.39
OR	$28.70	$82.90
PA	$57.18	$82.90
PR	$100.92	—
RI	$65.17	$82.90
SC	$65.17	$84.39
SD	$63.89	$84.79
TN	$65.17	$84.39
TX	$61.45	$84.39
UT	$42.78	$84.79
VA	$65.17	$82.90
VI	$100.92	—
VT	$65.17	$82.90
WA	$28.70	$82.90
WI	$55.32	$84.12
WV	$65.17	$82.90
WY	$42.78	$84.79

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

CO-50 medical necessity

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