HCPCS Level II › L codes L2525 Th/wght bear nar m-l brim moAddition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim molded to patient model
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 L2525 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $1,400.77 to $1,867.69 in the contiguous states; $1,612.11 to $1,889.47 in AK, HI, PR and VI; ceiling $1,867.69, floor $1,400.77 Payer policies and prior authorization for L2525 22 of 22 payer prior-auth lists that name L2525 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, CarePlus Health Plans, Humana, Medicare, Molina Complete Care (Virginia), Molina Healthcare of Idaho, Molina Healthcare of Mississippi, Molina Healthcare of Texas, Molina Healthcare of Utah, UnitedHealthcare Community Plan.
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 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 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 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 LA prior auth required Jan 1, 2027 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate 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 Molina Complete Care (Virginia) Medicaid VA prior auth required Apr 1, 2025 Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 Molina Healthcare of Idaho Medicaid ID prior auth required Jan 1, 2025 Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 Molina Healthcare of Mississippi Medicaid MS prior auth required Jan 1, 2025 Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 Molina Healthcare of Texas STAR TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 Molina Healthcare of Texas STAR+PLUS TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 Molina Healthcare of Utah Medicaid UT prior auth required Jan 1, 2025 Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 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 L2525 L2525 appears in 3 coverage policies from Aetna, Anthem, Cigna.
Payer Policy Role in policy Reviewed Document Aetna Orthopedic Casts, Braces and Splints (0009) listed, no stance (range L1600-L2999) Jan 20, 2026 payer document Anthem Ankle-Foot and Knee-Ankle-Foot Orthoses (CG-OR-PR-13) covered if criteria are met (range L2500-L2550) Aug 13, 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 Jul 1, 2026: PA removed, Molina Healthcare of Texas Mar 1, 2026: PA removed, Humana Jan 1, 2026: PA removed, Passport by Molina Healthcare (Kentucky) Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Texas Jul 1, 2024: PA added, Molina Complete Care (Virginia) Jul 1, 2024: PA added, Molina Healthcare of Mississippi Medicaid fee-for-service Prior authorization required or conditional in CO, IL, KY, LA, MA, MD, MS, ND, NE, NY, VA, WA, WV.
AZ: $1460.71 (dme), effective Oct 1, 2026 CO: $1080.79 (chp_plus, non-facility), effective Jul 1, 2026 FL: $676.53 (dme), effective Jul 1, 2026 IL: $1138.26 (dme), effective Jan 1, 2026 IN: $1167.31 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $1227.66 (default), effective Jul 1, 2026 KY: $1134.81 (dme), effective Jan 1, 2026 LA: $760.42 (dme), effective Jul 1, 2012 MA: $1638.27 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $1267.59 (dme), effective Apr 1, 2026 MS: $1452.94 (comprehensive), effective Jul 1, 2026 ND: $1812.73 (dme), effective Aug 1, 2026 NE: $1317.64 (dme), effective Jul 1, 2026 NY: $1198.52 (dme), effective Jul 1, 2026 OH: $728.22 (dme), effective Jan 1, 2010 OK: $980.54 (dme), effective Jan 1, 2026 TX: $750.58 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Feb 1, 1993 VA: $1342.15 (dme), effective Dec 1, 2026 VT: $1565.56 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $1120.69 (prosthetics_orthotics), effective Jul 1, 2026 WY: $969.75 (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.