Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
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 1 units per day (policy), rationale: Code Descriptor / CPT Instruction
DME supplier: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction
Medicare pricing for L3650
DMEPOS fee schedule, July 2026 (DME26-C)
no modifier, prosthetics and orthotics (PO): non-rural $66.69 to $88.92 in the contiguous states; $76.59 to $105.67 in AK, HI, PR and VI; ceiling $88.92, floor $66.69
Payer policies and prior authorization for L3650
Payer coverage policies that name L3650
L3650 appears in 2 coverage policies from Aetna, Cigna.
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.