L0454 Tlso trnk sj-t9 pre cstTlso flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0454 appears in 5 coverage policies from Aetna, Anthem, Cigna, Regence.
| 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 (range L0454-L0472) | 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 |
| Regence | Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar (Durable Medical Equipment 97) | listed, no stance | May 1, 2026 | payer document |
Prior authorization required or conditional in MA, MS, NY, OH, VA.
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.