HCPCS Level II › L codes L0639 Lso s/c shell/panel prefabLumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
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 L0639 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $1,288.60 to $1,682.10 in the contiguous states; $1,288.60 to $1,590.09 in AK, HI, PR and VI; ceiling $1,718.13, floor $1,288.60 Payer policies and prior authorization for L0639 20 of 20 payer prior-auth lists that name L0639 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, CarePlus Health Plans, Humana, Medicare, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source Blue Cross Blue Shield of Arizona (AZ Blue) AZ Blue-administered Medicare Advantage (M2K) AZ prior auth required Sep 1, 2026 AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) Blue Shield of California Promise Health Plan Promise Health Plan Medi-Cal CA prior auth required Sep 1, 2026 Medi-Cal Prior Authorization List Medicare DMEPOS Master List (items potentially subject to PA) All prior auth under conditions On the Master List; PA only if CMS selects it for the Required List Jul 30, 2026 Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements Medicare DMEPOS Required Prior Authorization All prior auth required Aug 12, 2024 Required Prior Authorization List 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 LA prior auth required Jan 1, 2027 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate Humana Humana Healthy Horizons SC prior auth required Jan 1, 2027 Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical 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 L0639 L0639 appears in 6 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 Orthopedic Casts, Braces and Splints (0009) covered if criteria are met Jan 20, 2026 payer document Aetna Spinal Surgery: Laminectomy and Fusion (0743) listed, no stance (range L0625-L0651) Jul 30, 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
Recent prior-auth changes Jan 1, 2027: PA added, Humana Oct 1, 2026: PA removed, Oxford Health Plans Medicaid fee-for-service Prior authorization required or conditional in IL, KY, LA, MA, MD, MS, NE, NY, OH, VA, WV.
AZ: $1215.85 (dme), effective Oct 1, 2026 CO: $676.09 (chp_plus, non-facility), effective Jul 1, 2026 FL: $1093.37 (dme), effective Jul 1, 2026 IL: $1115.95 (dme), effective Jan 1, 2026 IN: $1326.77 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $1165.24 (default), effective Jul 1, 2026 KY: $1101.92 (dme), effective Jan 1, 2026 LA: $814.86 (dme), effective Jul 1, 2012 MA: $1074.72 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $1095.31 (dme), effective Apr 1, 2026 MS: $1345.68 (comprehensive), effective Jul 1, 2026 NE: $1250.62 (dme), effective Jul 1, 2026 NY: $852.57 (dme), effective Jul 1, 2026 OH: $827.69 (dme), effective Jan 1, 2010 OK: $1050.71 (dme), effective Jan 1, 2026 TX: $735.80 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Mar 1, 2026 VA: $1159.74 (dme), effective Dec 1, 2026 VT: $1177.33 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $1013.28 (prosthetics_orthotics), effective Jul 1, 2026 WY: $881.59 (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.