L3640 Shoe dennis browne splint boTransfer of an orthosis from one shoe to another, dennis browne splint (riveton), both shoes
3 of 3 payer prior-auth lists that name L3640 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Rocky Mountain Health Plans.
| 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 | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
L3640 appears in 3 coverage policies from Aetna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Foot Orthotics (0451) | covered if criteria are met (range L3500-L3649) | 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 L3300-L3649) | Apr 27, 2026 | payer document |
Prior authorization required or conditional in CO, LA, MA, 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.