L2755 Carbon graphite laminationAddition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only
4 of 4 payer prior-auth lists that name L2755 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, UnitedHealthcare, 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 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
L2755 appears in 7 coverage policies from Aetna, Anthem, Blue Shield of California, Cigna, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (0565) | covered if criteria are met | Aug 26, 2026 | payer document |
| Aetna | Knee Braces (1094) | covered if criteria are met | Jan 20, 2026 | payer document |
| Aetna | Knee Braces (1094) | listed, no stance | Jan 20, 2026 | payer 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 L2570-L2830) | Aug 13, 2026 | payer document |
| Blue Shield of California | BSC1.05 | Knee Braces (Custom) | listed, no stance | payer document | |
| Cigna | Orthotic Devices and Shoes (0543) | covered if criteria are met | Sep 15, 2026 | payer document |
| Premera Blue Cross | Custom-made Knee Orthoses (Braces), Ankle-Foot-Orthoses, and Knee-Ankle-Foot-Orthoses (1.03.501) | listed, no stance | Feb 9, 2026 | payer document |
Prior authorization required or conditional in IL, LA, MA, MS, NY, VA, WV.
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.