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Physician Order Prescription and Certificate of Medical Necessity for Lumbar Sacral Orthosis LSO Date Patient Name Address Medicare City State Date of Birth Zip Code Male Female MM / DD / YYYY Dr. Information Treating Physician NPI Office Phone Office Fax It is in my expert opinion that a LSO HCPCS Code L0631 or L0637 is medically necessary to facilitate management of this patient s diagnosis. This prescription also acts as the Letter of Medical Necessity. Please dispense as written. To Facilitate healing following a surgical procedure on the spine or related soft tissue. Information Treating Physician NPI Office Phone Office Fax It is in my expert opinion that a LSO HCPCS Code L0631 or L0637 is medically necessary to facilitate management of this patient s diagnosis. This prescription also acts as the Letter of Medical Necessity. Please dispense as written* To Facilitate healing following a surgical procedure on the spine or related soft tissue. Date of procedure Description To Reduce pain by restricting mobility of the trunk. To Otherwise support weak spinal muscles and/or a deformed spine. I certify that the following statement is true Lumbago 724. 2 Spinal Stenosis 724. 0 Muscle Weakness 728. 87 Spondylolisthesis 756. 12 Lumbar Disc Displacement 722. 10 check all that apply Lumbosacral Sponsylosis 721. 3 Lumbar Strains / Sprain 847. 2 Spinal Disorder 724. 9 Lumbar/Lumbosacral Intervertebral Disc Degeneration 722. 52 Duration Patient has had this condition for month s years. Chronic 3 months or more Estimated Length of Back Brace Need of Months 1-99 99 Lifetime Our evaluation of the above patient has determined that providing the following back pain management Lumbar sacral orthosis product will benefit this patient. Check the appropriate box below for Quantity 1 Back Brace LO627 Flex Power Plus LO Lumbar Orthosis Sagittal control with posterior support that extends from L-1 below L-5 Beneficial for multiple level decompression laminectomy posterior lateral fusion* LO637 Prot g / Tri-Mod LSO Lumbar Sacral Orthosis Sagittal coronal control back brace with posterior support that extends from sacrococygeal junction to T-9 vertebra* Indicators included by not limited Post-operative stabilization protocol following spinal fusion laminectomy/laminotomy foraminotomy laproscopic disk replacement IDET procedures. Multi-level decompression Bust fractures Chronic mechanical low back pain* LO631 Passport / Premium Plus LSO Lumbar Sacral Orthosis Sagittal control back brace with Degenerative and bulging discs Herniatged/bulging discs Spinal senosis Spondylolisthesis Facet syndrome thoracolumbar injury evision surgery multi-level fusion* Lumbara sacral mechanical back pain* Physician Signature M. D. or D. O. Date If a CRNP or PA signs Rx to meet Medical Guidelines an M. D. or D. O. wet ink or stamped Signature must accompany signature. This prescription also acts as the Letter of Medical Necessity. Please dispense as written* To Facilitate healing following a surgical procedure on the spine or related soft tissue. Date of procedure Description To Reduce pain by restricting mobility of the trunk. To Otherwise support weak spinal muscles and/or a deformed spine. .

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