ABC Medical Billing Company
555 North Main Street
Anytown, DE 01205
555-555-5555
Prescription, Pre-Auth & Medical Necessity Certification for LSO Brace – L0627, L0631, L0637
Patients Name: _____________________________________________________ DOB: _____________ ID #: _________________
Onset of DX’s: _____________________________________________________________________________________
Diagnosis:
1. ___________________________________
3. _______________________________________
2. ___________________________________
4. _______________________________________
Diagnosis:
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724.2
Low Back Pain
( ) 724.9
Nerve Root Compression
728.85 Muscle Spasm
( ) 722.10 Disc Displacement w/o myelo
728.9
Muscle Tightness
( ) 722.73 Disc Displacement w/ myelo
728.4
Ligamentous Instability
( ) 722.52 Lumbar Disc Degeneration
781.92 Abnormal Posture
( ) 847.2
Lumbar Sprain/Strain
737.10 Kyphosis
( ) 724.4
Lumbar neuritis/radiculitis
721.9
Spondylosis
Other: _______________________________________________________________________
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Relaxation of muscle spasm
Absent Lumbar curvature causing pain
Reverse Lumbar curvature causing pain
Muscle re-education
Expected Benefits (check all appropriate)
 Significantly reduce medication, as to frequency
and amount
 Significantly increase mobility without pain
 Significant reduction of pain
 Improvement of postural/musculoskeletal abnormalities
Duration of need:
Prognosis:
 12 Months
 Fair
 Reduction of neurological symptomatology
 Symptomatic relief and management of chronic pain
 Adjunctive treatment in the management of
post- traumatic acute pain
 Improved clinical picture
 Avoidance of drug dependency
 Reduce exacerbations of disc injury
 Increase stabilization of Spine/SI joint
 Increase the stability of Spondylolesthesis
Alternative Modalities Used:
 Stretching
 Electrical Stimulation
 Life
 Good
 Manual Therapies
 Intersegmental Traction
 PRN Pain (use indefinitely)
 Excellent
 Hot/Cold Therapies
 Neuromuscular Techniques
 Ultrasound/Iontophoresis
Medicines previously tried dosage, duration and outcome.
____________________________________________________________________________________________________________
Instructions for use: Freq of use (___times per day); Length of use (___days, weeks, months); Time of Treatment (30 min, other___)
_____The L0631, Lumbar-Sacral Orthosis, helps alleviate pain and speed rehabilitation by providing effective stabilization and
unloading on the spine. It has 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 discs, includes straps, closures, may
include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.
_____The L0637, Lumbar-Sacral Orthosis, Sagittal Coronal Control helps alleviate pain and speed rehabilitation by providing
effective stabilization and unloading on the spine. Lateral strength is provided by Rigid Lateral Frame/Panels. It has sagittal –coronal
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 discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, includes fitting and adjustment.
_____The L0627, Lumbar-Sacral Orthosis, helps alleviate pain and speed rehabilitation by providing effective stabilization and
unloading on the spine. It has sagittal control, with rigid anterior and posterior panels, posterior extends from L1-L5 Vertebra. It
produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder
straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.
Utilizing accepted medical practice standards the above-prescribed durable medical equipment is essential in the continuous treatment
of this patient.
Physician’s Signature: ________________________________________________ Date: _____ / _____ / ________
Physicians Name: __________________________________________________
Tax ID#: 45-1558702