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 L4130
DMEPOS fee schedule, July 2026 (DME26-C)
no modifier, prosthetics and orthotics (PO): non-rural $570.11 to $760.15 in the contiguous states; $523.52 to $815.92 in AK, HI, PR and VI; ceiling $760.15, floor $570.11
Payer policies and prior authorization for L4130
6 of 6 payer prior-auth lists that name L4130 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, Humana, Medicare, Rocky Mountain Health Plans.
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.