L0643 Lso sag ctr rigi pos pre otsLumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
2 of 2 payer prior-auth lists that name L0643 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, Medicare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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 Probationary Prior Authorization (new suppliers) | All | prior auth under conditions | Newly enrolled or changed-ownership suppliers in their probationary year | Oct 15, 2026 | DMEPOS Probationary Prior Authorization List |
L0643 appears in 5 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 | 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 |
Prior authorization required or conditional in LA, 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.