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1 November 11, 2010 ATTN STEVE LUSKY 341 A WEST MAIN ST Xref #: Product: XBack ProLift Model number: T1 08 Dear Me Lusky: L0631 -LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TOT -9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL This decision applies to the application that we received on August 30, 2010, If our decision, Therefore, a new application would need to be submitted for HCPCS coding verification review, This coding decision will be available within ten (10) working days on the Durable Medical Equipment Coding System (DMECS), which is located on the PDAC web site, \\Y,'\,Y,_Q111e]Qfl(; C:Q!_n, Please take the time to verify that this coding decision is correctly reflected in DMECS, CENTERS for MEDICARE & MEDICAID SERVICES A CMS Contracted Medtcare Administrative Comractor (1993)4-09

2 June 21, A WEST MAIN ST Xref#: Product: XBACK POSTURE CORREX ~odelnumber:t106 L0627- LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES This decision applies to the application that we received on April 1, If information submitted in that application has changed or were to change, it could impact our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. This coding decision will be available within ten (1 0) working days on the Durable Medical Equipment Coding System (DMECS), which is located on the PDAC web site, Please take the time to verify that this coding decision is correctly reflected in DMECS.

3 June 16, A WEST MAIN ST Xref#: Product: XBACK SOLUTION ES Model number: T1 05 L LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL This decision applies to the application that we received on March 30, If our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. This coding decision will be available within ten (10) working days on the Durable Medical Equipment Coding System (DMECS), which is located on the PDAC web site, Please take the time to verify that this coding decision is correctly reflected in DMECS.

4 - Fargo. ND November 2, 2009 ATTN STEVEN LUSKY 341A WMAIN STREET BIRDSBORO PA Product: XBack LS Xref #: Model number: T103 L0627 LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES This decision applies to the application that we received on August 13, If our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. guarantee claim reimbursement or coverage. If you have questions about claim coverage or reimbursement, please contact the DME MAC for your jurisdiction.

5 /~ and Coding {PDAC) May 12,2009 ATTN: STEVEN A LUSKY 341A W MAIN STREET BIRDSBORO PA Product: XBack Compression Model number: T101 Xref #: L0637- LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T -9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL This product was previously coded as L0631. The DME Coding System (DMECS) will be updated to reflect this change. This decision applies to the application that we received on March 20, If information submitted in that application has changed or were to change, it could impact our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. CENT /IS for MEDICA/IE & MEIJICA//J SEIIVICES

6 /~, nd Street Soutl1 February 9, A W MAIN ST BIRDSBORO PA Xref #: Product: XBACK COMPRESSION ES Model number: T104 L0637- LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL The requested code, L0639, was not assigned to this product. The Article for Spinal Orthoses: TLSO and LSO- Policy Article- Effective January 2010 states: "the body jacket type orthoses (L0458-L0464, L0480-L0492, L0639, L0640) are characterized by a rigid plastic shell that encircles the tnmk with overlapping edges and stabilizing closures and provides a high degree of immobility. The entire circumference of the plastic shell must be the same rigid material." The product submitted for review does not meet these guidelines as the panels do not overlap. C NTfiiS far M lj/c4ffe & MfPIC4/lJ Sf/IVICES

7 Fargo, NO June 14, A WEST MAIN ST Xref #: Product: XBACK II Model number: T100 L0631- LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL The HCPCS code L0456 was requested for this product. L0456 is for a flexible TLSO. The product submitted for review has a rigid posterior and anterior panel with the posterior panel extending from the sacrococcygeal junction to the T9 vertebra. This product meets the requirements for L0631. This decision applies to the application that we received on March 26, If our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. This coding decision will be available within ten (1 0) working days on the Durable Medical Equipment Coding System (DMECS), which is CENTERS fur MEDICME & MffJ/CA/iJ SERVICES

8 Fargo, NO January 3, A WEST MAIN STREET Xref #: Product: XBack Spondy Model number: T107 L0637- LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME!P ANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME!P ANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL This decision applies to the application that we received on October 20, If our decision. Therefore, a new application would need to be submitted for HCPCS coding verification review. This coding decision will be available within ten (10) working days on the Durable Medical Equipment Coding System (DMECS), which is located on the PDAC web site, Please take the time to verify that this coding decision is correctly reflected in DMECS. cwrs/ A CMS Contracted Medicare Administrative Contractor (1 993) 4-09