`L0488` Tlso rigid lined pre one pie

Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment

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 L0488

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, prosthetics and orthotics (PO): non-rural $1,204.08 to $1,247.22 in the contiguous states; $1,204.08 to $1,324.46 in AK, HI, PR and VI; ceiling $1,469.43, floor $1,102.07

Payer policies and prior authorization for L0488

14 of 14 payer prior-auth lists that name L0488 require prior authorization or set conditions: CarePlus Health Plans, Humana, 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	KY	prior auth required		Jan 1, 2027	please visit Humana Healthy Horizons in Kentucky Clinical coverage policies.
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
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Kentucky	KY	prior auth under conditions	Cost over $500	Jul 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name L0488

L0488 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 (range L0488-L0621)	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
Feb 1, 2024: PA removed, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO, IL, KY, MA, MD, MS, ND, NE, NY, OH, VA, WV.

AZ: $1120.88 (dme), effective Oct 1, 2026
CO: $962.62 (chp_plus, non-facility), effective Jul 1, 2026
FL: $244.14 (dme), effective Jul 1, 2026
IL: $936.90 (dme), effective Jan 1, 2026
IN: $1028.07 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $982.10 (default), effective Jul 1, 2026
KY: $913.86 (dme), effective Jan 1, 2026
MA: $921.34 (orthotics_prosthetics_rates), effective Apr 1, 2024
MD: $1023.47 (dme), effective Apr 1, 2026
MS: $992.30 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NE: $1054.04 (dme), effective Jul 1, 2026
NY: $895.09 (dme), effective Jul 1, 2026
OH: $727.15 (dme), effective Dec 7, 2010
OK: $868.19 (dme), effective Jan 1, 2026
TX: $913.78 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Jul 1, 2010
VA: $1083.67 (dme), effective Dec 1, 2026
VT: $1009.30 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $767.95 (professional), effective Jan 1, 2021

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.

L0488 Tlso rigid lined pre one pie