HCPCS Level II › L codes L1843 Ko single upright pre cstKnee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 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 2 units per day (policy), rationale: Anatomic Consideration DME supplier: max 2 units per day (policy), rationale: Anatomic Consideration Medicare pricing for L1843 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $1,076.26 to $1,114.82 in the contiguous states; $1,076.26 to $1,183.90 in AK, HI, PR and VI; ceiling $1,313.43, floor $985.07 Payer policies and prior authorization for L1843 20 of 20 payer prior-auth lists that name L1843 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, HealthSpring, 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) 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 HealthSpring Medicare Advantage All prior auth required Mar 1, 2026 2026 Q4 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 IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . 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 OK prior auth required Jan 1, 2027 Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list 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 Texas STAR+PLUS TX prior auth required Jan 1, 2019 Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p 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 L1843 L1843 appears in 6 coverage policies from Aetna, Anthem, Blue Shield of California, Capital Blue Cross, Cigna.
Payer Policy Role in policy Reviewed Document Aetna Knee Braces (1094) covered if criteria are met Jan 20, 2026 payer document Aetna Knee Braces (1094) listed, no stance (range L1810-L1860) Jan 20, 2026 payer document Aetna Orthopedic Casts, Braces and Splints (0009) listed, no stance (range L1600-L2999) Jan 20, 2026 payer document Anthem Prefabricated and Prophylactic Knee Braces (CG-OR-PR-02) covered if criteria are met Feb 19, 2026 payer document Blue Shield of California BSC1.05 | Knee Braces (Custom) listed, no stance payer document Capital Blue Cross Knee Braces (MP 6.012)Procedure Codes covered if criteria are met Sep 1, 2026 payer document Cigna Orthotic Devices and Shoes (0543) covered if criteria are met Sep 15, 2026 payer document
Recent prior-auth changes Jan 1, 2027: PA added, Humana Oct 1, 2026: PA removed, Oxford Health Plans Jul 1, 2024: PA removed, Blue Shield of California Promise Health Plan Medicaid fee-for-service Prior authorization required or conditional in CO, IL, KY, LA, MA, MS, ND, NE, NY, OH, VA, WV.
AZ: $901.70 (dme), effective Oct 1, 2026 CO: $765.03 (chp_plus, non-facility), effective Jul 1, 2026 FL: $347.35 (dme, OS), effective Jul 1, 2026 IL: $896.05 (dme), effective Jan 1, 2026 IN: $918.93 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $658.38 (default, Mid Level Practitioner), effective Jul 1, 2026 KY: $692.73 (dme), effective Jan 1, 2026 LA: $601.80 (dme), effective Jul 1, 2012 MA: $823.54 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $914.82 (dme), effective Apr 1, 2026 MS: $886.93 (comprehensive), effective Jul 1, 2026 ND: $0.00 (dme), effective Aug 1, 2026 NE: $942.17 (dme), effective Jul 1, 2026 NY: $640.88 (dme), effective Jul 1, 2026 OH: $345.00 (dme), effective Jan 1, 2010 OK: $776.01 (dme), effective Jan 1, 2026 TX: $637.97 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Apr 1, 2015 VA: $968.63 (dme), effective Dec 1, 2026 VT: $902.16 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $808.90 (prosthetics_orthotics), effective Jul 1, 2026 WY: $686.43 (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.