L3675 So vest canvas/web pre ots

Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf

Medicare pricing for L3675

DMEPOS fee schedule, July 2026 (DME26-C)

Payer policies and prior authorization for L3675

Payer coverage policies that name L3675

L3675 appears in 2 coverage policies from Aetna, Cigna.

PayerPolicyRole in policyReviewedDocument
AetnaOrthopedic Casts, Braces and Splints (0009)listed, no stance (range L3650-L4398)Jan 20, 2026payer document
CignaOrthotic Devices and Shoes (0543)covered if criteria are metSep 15, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in MA, NY, VA.

  • AZ: $178.34 (dme), effective Oct 1, 2026
  • CO: $151.15 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $103.76 (dme, OS), effective Jul 1, 2026
  • IL: $120.87 (dme), effective Jan 1, 2026
  • IN: $163.59 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
  • KS: $156.25 (default), effective Jul 1, 2026
  • KY: $123.30 (dme), effective Jan 1, 2026
  • MA: $168.04 (orthotics_prosthetics_rates), effective Apr 1, 2024
  • MD: $162.84 (dme), effective Apr 1, 2026
  • ND: $226.63 (dme), effective Aug 1, 2026
  • NE: $167.67 (dme), effective Jul 1, 2026
  • NY: $142.55 (dme), effective Jul 1, 2026
  • OH: $118.84 (dme), effective Jan 1, 2010
  • OK: $138.13 (dme), effective Jan 1, 2026
  • TX: $120.86 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Mar 1, 1999
  • VA: $172.42 (dme), effective Dec 1, 2026
  • VT: $160.59 (outpatient_hospital_opps), effective Feb 1, 2026
  • WY: $122.18 (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.