HCPCS Level II › L codes L0452 Tlso flex custom fab thoraciTlso, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Outpatient hospital: max 1 units per day (policy), rationale: Anatomic Consideration DME supplier: max 1 units per day (policy), rationale: Anatomic Consideration Medicare pricing for L0452 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): no amount on file (priced by the DME MAC) Payer policies and prior authorization for L0452 32 of 33 payer prior-auth lists that name L0452 require prior authorization or set conditions: CarePlus Health Plans, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), UnitedHealthcare, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source CarePlus Health Plans CarePlus Health Plans FL prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana D-SNP (FL) FL prior auth required Jan 1, 2027 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois Prior Authorization and Notification List Humana Humana D-SNP (IN) IN prior auth required Jan 1, 2027 *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List Humana Humana D-SNP (MI) MI prior auth required Jan 1, 2027 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List Humana Humana D-SNP (SC) SC prior auth required Jan 1, 2027 Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List Humana Humana D-SNP (VA) VA prior auth required Jan 1, 2027 Virginia Prior Authorization and Notification List Humana Humana Healthy Horizons IN prior auth required Jan 1, 2027 1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a Humana Humana Healthy Horizons VA prior auth required Jan 1, 2027 Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) Humana Humana MA and D-SNP All prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana Puerto Rico MA and Dual Medicare-Medicaid PR prior auth required Nov 3, 2025 Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management Molina Complete Care (Virginia) Medicare-only PA matrix for D-SNP VA prior auth required Jan 1, 2022 Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 Molina Healthcare of Arizona Medicare-only PA matrix for D-SNP AZ prior auth required Jan 1, 2022 Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 Molina Healthcare of California Medicare Advantage CA prior auth required Jul 1, 2021 Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 Molina Healthcare of Florida Medicare Advantage FL prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 Molina Healthcare of Idaho Medicare Advantage ID prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 Molina Healthcare of Iowa Medicaid IA prior auth required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 Molina Healthcare of Michigan Exchange MI prior auth required Jul 1, 2021 Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 Molina Healthcare of Nevada Medicaid NV prior auth required Oct 1, 2022 Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 Molina Healthcare of New Mexico Medicare Advantage NM prior auth required Jan 1, 2021 Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 Molina Healthcare of Ohio Medicaid and MyCare Ohio (MMP) Medicaid OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of Ohio Medicare and MyCare Ohio (MMP) Medicare OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of Ohio Exchange OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of South Carolina Medicare Advantage SC prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 Molina Healthcare of Utah Medicare Advantage UT prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 Molina Healthcare of Washington Medicare Advantage WA prior auth required Apr 1, 2021 Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 Molina Healthcare of Wisconsin Medicare Advantage WI prior auth required Oct 1, 2021 Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 Molina Healthcare, Inc. (national grid) Molina national (MHI) Medicare grid All prior auth required Oct 1, 2021 Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 UnitedHealthcare UnitedHealthcare Complete (Individual & Family plans) All prior auth required Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 UnitedHealthcare UnitedHealthcare Individual Exchange plans All prior auth required Oct 1, 2026 Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 UnitedHealthcare Community Plan UnitedHealthcare Community Plan of Kentucky KY prior auth required Jul 1, 2026 Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026
Payer coverage policies that name L0452 L0452 appears in 4 coverage policies from Aetna, Anthem, Cigna.
Payer Policy Role in policy Reviewed Document Aetna Back Pain - Invasive Procedures (0016) listed, no stance (range L0112-L0999) Oct 6, 2026 payer document Aetna Back Pain - Invasive Procedures (0016) listed, no stance (range L0450-L0492) Oct 6, 2026 payer document Aetna Orthopedic Casts, Braces and Splints (0009) covered if criteria are met Jan 20, 2026 payer document Anthem Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar (CG-OR-PR-06) covered if criteria are met Feb 19, 2026 payer document Cigna Orthotic Devices and Shoes (0543) covered if criteria are met Sep 15, 2026 payer document
Recent prior-auth changes Jan 1, 2027: PA added, Humana May 1, 2026: conditions changed, UnitedHealthcare Apr 1, 2026: PA removed, UnitedHealthcare Community Plan Apr 1, 2026: conditions changed, UnitedHealthcare Jan 1, 2026: PA removed, Molina Healthcare of Michigan Feb 19, 2025: PA removed, Molina Healthcare of Texas Feb 19, 2025: PA removed, Molina Healthcare of Texas Jan 1, 2025: PA removed, Molina Healthcare of Texas Feb 1, 2024: PA removed, Blue Shield of California Promise Health Plan Jan 1, 2024: PA removed, Molina Healthcare of Michigan Medicaid fee-for-service Prior authorization required or conditional in CO, IL, KY, MA, MD, MS, NY, OH, VA, WA.
AZ: $300.04 (dme), effective Oct 1, 2026 CO: $313.44 (health_first_colorado), effective Jul 1, 2026 FL: $244.14 (dme), effective Jul 1, 2026 IL: $256.09 (dme), effective Jan 1, 2026 IN: $283.85 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $125.20 (default), effective Jan 1, 2006 KY: $271.28 (dme), effective Jan 1, 2026 NY: $334.16 (dme), effective Jul 1, 2026 OH: $202.07 (dme), effective Jan 1, 2010 TX: $263.81 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Jun 1, 2003 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $257.17 (professional), effective Apr 1, 2025 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.