`L3891` Torsion mechanism wrist/elbo

Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

Medicare coverage: Not payable by Medicare
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 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 0 units per day (clinical), rationale: Published Contractor Policy

Payer policies and prior authorization for L3891

Payer coverage policies that name L3891

L3891 appears in 2 coverage policies from Aetna, Cigna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Orthopedic Casts, Braces and Splints (0009)	listed, no stance (range L3650-L4398)	Jan 20, 2026	payer document
Cigna	Orthotic Devices and Shoes (0543)	covered if criteria are met	Sep 15, 2026	payer document

Medicaid fee-for-service

Prior authorization required or conditional in IL, KY, LA, MS, NY, OH, VA.

IN: $292.84 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
OH: $300.00 (dme), effective Jan 1, 2026
OK: $129.86 (dme), effective Aug 1, 2020
TX: $308.29 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Mar 1, 2023
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

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.

L3891 Torsion mechanism wrist/elbo

Medically Unlikely Edits (effective October 1, 2026)

Payer policies and prior authorization for L3891

Payer coverage policies that name L3891

Medicaid fee-for-service

`L3891` Torsion mechanism wrist/elbo