`L3921` Hfo w/joint(s) cf

Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

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 2 units per day (policy), rationale: Anatomic Consideration
DME supplier: max 2 units per day (policy), rationale: Anatomic Consideration

Medicare pricing for L3921

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, prosthetics and orthotics (PO): non-rural $350.66 to $363.16 in the contiguous states; $350.66 to $385.70 in AK, HI, PR and VI; ceiling $427.91, floor $320.93

Payer policies and prior authorization for L3921

2 of 2 payer prior-auth lists that name L3921 require prior authorization or set conditions: UnitedHealthcare.

Payer	Plan	State	Prior auth	Conditions	Since	Source
UnitedHealthcare	UnitedHealthcare Complete (Individual & Family plans)	All	prior auth required		Sep 1, 2026	Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026

Payer coverage policies that name L3921

L3921 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

Recent prior-auth changes

May 1, 2026: conditions changed, UnitedHealthcare
Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
Apr 1, 2026: conditions changed, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in MA, MS, NY, OH, VA, WA, WV.

AZ: $326.43 (dme), effective Oct 1, 2026
CO: $276.62 (chp_plus, non-facility), effective Jul 1, 2026
IN: $299.40 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KS: $285.98 (default), effective Jul 1, 2026
MA: $307.58 (orthotics_prosthetics_rates), effective Apr 1, 2024
MD: $298.06 (dme), effective Apr 1, 2026
MS: $288.94 (comprehensive), effective Jul 1, 2026
ND: $375.28 (dme), effective Aug 1, 2026
NE: $306.94 (dme), effective Jul 1, 2026
NY: $248.52 (dme), effective Jul 1, 2026
OH: $275.02 (dme), effective Jan 1, 2026
OK: $252.80 (dme), effective Jan 1, 2026
TX: $184.18 (dmepos_tos_9_e_j_l_and_r, Hospital - Long Term, Limited, Or Specialized Ca, facility), effective Jan 1, 2006
VA: $315.59 (dme), effective Dec 1, 2026
VT: $293.93 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $26.35 (prosthetics_orthotics), effective Jul 1, 2026
WY: $223.62 (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.

L3921 Hfo w/joint(s) cf