L4205 Ortho dvc repair per 15 minRepair of orthotic device, labor component, per 15 minutes
2 of 2 payer prior-auth lists that name L4205 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 |
L4205 appears in 4 coverage policies from Aetna, Blue Shield of California, 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 |
| Blue Shield of California | BSC1.05 | Knee Braces (Custom) | listed, no stance | payer document | |
| Cigna | Orthotic Devices and Shoes (0543) | covered if criteria are met | Sep 15, 2026 | payer document |
Prior authorization required or conditional in KY, LA, MA, ND, NY, OH, VA, WA, 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.