L0635 — Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
HCPCS Level II L-code · short descriptor: “Lso sagit rigid panel prefab”
- 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
- Required (Orthoses)
- 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))
F2F + WOPD REQUIRED L0635 is on Medicare's Required Face-to-Face & WOPD List (Orthoses — 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)). Two extra conditions of payment apply:
- Face-to-face encounter (in-person or telehealth) with the treating practitioner within the 6 months before the order date
- Written order communicated to the supplier before delivery (WOPD)
Blank requirements checklist only — MyMedi-AI never collects or stores completed orders.
L0635 Medicare fee schedule (October 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $1099.93 to $2147.80 depending on state and rural status.
Former-CBA payment limits: ceiling $1466.58 · floor $1099.93
| State | Non-rural | Rural |
|---|---|---|
| AK | $2008.56 | — |
| AL | $1313.90 | — |
| AR | $1222.44 | — |
| AZ | $1466.58 | — |
| CA | $1466.58 | — |
| CO | $1099.93 | — |
| CT | $1123.96 | — |
| DC | $1099.93 | — |
| DE | $1099.93 | — |
| FL | $1313.90 | — |
| GA | $1313.90 | — |
| HI | $2147.80 | — |
| IA | $1229.97 | — |
| ID | $1267.50 | — |
| IL | $1228.02 | — |
| IN | $1228.02 | — |
| KS | $1229.97 | — |
| KY | $1313.90 | — |
| LA | $1222.44 | — |
| MA | $1123.96 | — |
| MD | $1099.93 | — |
| ME | $1123.96 | — |
| MI | $1228.02 | — |
| MN | $1228.02 | — |
| MO | $1229.97 | — |
| MS | $1313.90 | — |
| MT | $1099.93 | — |
| NC | $1313.90 | — |
| ND | $1099.93 | — |
| NE | $1229.97 | — |
| NH | $1123.96 | — |
| NJ | $1169.32 | — |
| NM | $1222.44 | — |
| NV | $1466.58 | — |
| NY | $1169.32 | — |
| OH | $1228.02 | — |
| OK | $1222.44 | — |
| OR | $1267.50 | — |
| PA | $1099.93 | — |
| PR | $1309.07 | — |
| RI | $1123.96 | — |
| SC | $1313.90 | — |
| SD | $1099.93 | — |
| TN | $1313.90 | — |
| TX | $1222.44 | — |
| UT | $1099.93 | — |
| VA | $1099.93 | — |
| VI | $1169.32 | — |
| VT | $1123.96 | — |
| WA | $1267.50 | — |
| WI | $1228.02 | — |
| WV | $1099.93 | — |
| WY | $1099.93 | — |
Unit limit (MUE)
Medicare's Medically Unlikely Edit caps L0635 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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