HCPCS Level II › L codes L5654 Socket insert symesAddition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal)
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 (clinical), rationale: Anatomic Consideration Medicare pricing for L5654 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $406.02 to $541.35 in the contiguous states; $429.97 to $526.55 in AK, HI, PR and VI; ceiling $541.35, floor $406.02 Payer policies and prior authorization for L5654 18 of 18 payer prior-auth lists that name L5654 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, CarePlus Health Plans, Humana, Rocky Mountain Health Plans.
Payer Plan State Prior auth Conditions Since Source Blue Cross Blue Shield of Arizona (AZ Blue) Federal Employee Program (FEP) AZ prior auth under conditions FEP Blue Focus only Sep 1, 2026 Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) Blue Shield of California Promise Health Plan Promise Health Plan Medi-Cal CA prior auth required Sep 1, 2026 Medi-Cal Prior Authorization List CarePlus Health Plans CarePlus Health Plans FL prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana D-SNP (FL) FL prior auth required Jan 1, 2027 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois Prior Authorization and Notification List Humana Humana D-SNP (IN) IN prior auth required Jan 1, 2027 *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List Humana Humana D-SNP (MI) MI prior auth required Jan 1, 2027 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List Humana Humana D-SNP (SC) SC prior auth required Jan 1, 2027 Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List Humana Humana D-SNP (VA) VA prior auth required Jan 1, 2027 Virginia Prior Authorization and Notification List 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 OH prior auth required Jan 1, 2027 555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list Humana Humana Healthy Horizons OK prior auth required Jan 1, 2027 Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list 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 Humana MA and D-SNP All prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List Humana Humana Puerto Rico MA and Dual Medicare-Medicaid PR prior auth required Nov 3, 2025 Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management 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
Payer coverage policies that name L5654 L5654 appears in 17 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.
Payer Policy Role in policy Reviewed Document Aetna Lower Limb Prostheses (0578) covered if criteria are met (range L5000-L5782) Oct 9, 2026 payer document Anthem Lower Limb Prosthesis (CG-OR-PR-12) covered if criteria are met (range L5654-L5698) Aug 13, 2026 payer document Blue Cross & Blue Shield of Mississippi Prosthetics (L.1.04.401) covered if criteria are met payer document Blue Shield of California BSC1.01 | Lower Limb Prostheses listed, no stance payer document Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) Lower-Limb Prosthetics, Including Microprocessor-Controlled Prosthetics (DME104.012)HCPCS Codes L2221, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, listed, no stance Jan 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (2026T0645N) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (CS361.H) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Idaho Only) (CS361ID.F) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Kansas Only) (CS361KS.05) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Kentucky Only) (CS361KY.07) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Nebraska Only) (CS361NE.G) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for New Jersey Only) (CS361NJ.H) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for New Mexico Only) (CS361NM.F) listed, no stance Aug 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for North Carolina Only) (CSNCT0361.05) listed, no stance Mar 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Ohio Only) (CS361OH.F) listed, no stance Apr 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Pennsylvania Only) (CS361PA.G) listed, no stance Sep 1, 2026 payer document UnitedHealthcare Lower Extremity Prosthetics (for Tennessee Only) (CS361TN.H) listed, no stance Sep 1, 2026 payer document
Recent prior-auth changes Jan 1, 2027: PA added, Humana Medicaid fee-for-service Prior authorization required or conditional in LA, MA, MS, NY, OH, VA.
AZ: $464.36 (dme), effective Oct 1, 2026 CO: $280.11 (chp_plus, non-facility), effective Jul 1, 2026 FL: $218.57 (dme), effective Jul 1, 2026 IL: $392.29 (dme), effective Jan 1, 2026 IN: $402.31 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $347.19 (default), effective Jul 1, 2026 KY: $253.68 (dme), effective Jan 1, 2026 LA: $261.98 (dme), effective Jul 1, 2012 MA: $474.86 (orthotics_prosthetics_rates), effective Apr 1, 2024 MD: $345.12 (dme), effective Apr 1, 2026 MS: $324.82 (comprehensive), effective Jul 1, 2026 ND: $0.00 (dme), effective Aug 1, 2026 NE: $372.60 (dme), effective Jul 1, 2026 NY: $212.10 (dme), effective Jul 1, 2026 OH: $250.96 (dme), effective Jan 1, 2010 OK: $337.83 (dme), effective Jan 1, 2026 TX: $279.67 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Apr 1, 1992 VA: $218.73 (medical), effective Aug 1, 1994 VT: $453.78 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $356.47 (prosthetics_orthotics), effective Jul 1, 2026 WY: $277.77 (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.