L4100 Repl leath cuff kafo prox thReplace leather cuff kafo, proximal thigh
2 of 2 payer prior-auth lists that name L4100 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, Rocky Mountain Health Plans.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth required | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
L4100 appears in 4 coverage policies from Aetna, Anthem, Cigna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (0565) | covered if criteria are met | Aug 26, 2026 | payer document |
| Aetna | Orthopedic Casts, Braces and Splints (0009) | listed, no stance (range L3650-L4398) | Jan 20, 2026 | payer document |
| Anthem | Ankle-Foot and Knee-Ankle-Foot Orthoses (CG-OR-PR-13) Replacements/repairs | covered if criteria are met (range L4002-L4130) | Aug 13, 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 IL, LA, MA, MS, NY, VA, WV.
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.