L3976 Sewhfo airplane w/o jnts cfShoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
42 of 42 payer prior-auth lists that name L3976 require prior authorization or set conditions: Humana, Medicare, Neighborhood Health Partnership, Rocky Mountain Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Medicare | DMEPOS Master List (items potentially subject to PA) | All | prior auth under conditions | On the Master List; PA only if CMS selects it for the Required List | Jul 30, 2026 | Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements |
| Humana | Humana Healthy Horizons | IN | prior auth required | Jan 1, 2027 | 1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a | |
| Humana | Humana Healthy Horizons | SC | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical | |
| Humana | Humana Healthy Horizons | VA | prior auth required | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) | |
| Humana | Oak Street Health | All | prior auth required | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management | ||
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | Prior authorization required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| Surest | Surest health plans | All | prior auth under conditions | Cost over $1,000 | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth under conditions | Prior authorization required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| 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 | |
| UnitedHealthcare | UnitedHealthcare Mid-Atlantic Health Plans | All | prior auth under conditions | Prior authorization required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare West commercial plans | All | prior auth under conditions | Prior authorization is required only for orthotics codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare of the River Valley | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | KanCare | KS | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Kansas Medicaid Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| UnitedHealthcare Community Plan | Minnesota Metro Medicaid | MN | prior auth under conditions | Prior authorization required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500 | Oct 1, 2024 | Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024 |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth under conditions | Prior authorization is required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed, with a retail purchase or cumulative rental cost of more than $500 | Apr 1, 2025 | Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | Missouri Medicaid | MO | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Jul 1, 2026 | Prior authorization requirements for Missouri Medicaid Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Nebraska Heritage Health | NE | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $750 | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United |
| UnitedHealthcare Community Plan | New Jersey FamilyCare | NJ | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Jersey Effective October 1, 2026 General Information This list contains prior authorization requirements for participating U |
| UnitedHealthcare Community Plan | New Mexico Turquoise Care | NM | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Pennsylvania CHIP | PA | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Pennsylvania Medicaid | PA | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Rhode Island Medicaid | RI | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | May 1, 2026 | Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth under conditions | Prior authorization is required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care | |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h | |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth under conditions | Prior authorization is required only for orthotics and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Nov 1, 2016 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth required | Jan 1, 2015 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Florida | FL | prior auth under conditions | Prior authorization required only for orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500 | Oct 1, 2026 | Prior authorization requirements for UnitedHeathcare Community Plan of Florida Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth under conditions | Prior authorization is required only for the orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care LTSS | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care LTSS Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Virginia Cardinal Care Medicaid | VA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for Virginia Cardinal Care Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Oct 1, 2026 | Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023 |
| UnitedHealthcare Community Plan | Wisconsin BadgerCare Plus and Medicaid SSI | WI | prior auth under conditions | Prior authorization required only for orthotic and prosthetics with a retail purchase or a cumulative rental cost of more than $500. | Sep 1, 2026 | Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community |
L3976 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 |
Prior authorization required or conditional in CO, MA, MD, MS, NE, NY, OH, VA, WA, WV, WY.
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.