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
- 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.
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
Related L-codes
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