L3204 Hightop w/ supp/pronator infOrthopedic shoe, hightop with supinator or pronator, infant
3 of 3 payer prior-auth lists that name L3204 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Humana.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Humana | Humana Healthy Horizons | SC | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical |
L3204 appears in 4 coverage policies from Aetna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Bunionectomy (0629) | listed, no stance (range L3201-L3265) | Sep 11, 2026 | payer document |
| Aetna | Foot Orthotics (0451) | covered if criteria are met (range L3201-L3265) | Jul 16, 2026 | payer document |
| Aetna | Pedobarography (0294) | listed, no stance (range L3000-L3649) | Apr 17, 2026 | payer document |
| Aetna | Plantar Fasciitis Treatments (0235) | listed, no stance (range L3000-L3265) | Apr 27, 2026 | payer document |
Prior authorization required or conditional in KY, LA, MA, MD, MS, NY, OH, VA.
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.