HCPCS Level II › L codes L5841 Addition endoskletl knee-shiAddition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) DME supplier: max 2 units per day (policy), rationale: Anatomic Consideration Medicare pricing for L5841 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, prosthetics and orthotics (PO): non-rural $2,814.38 to $3,818.92 in the contiguous states; $2,699.30 to $5,233.00 in AK, HI, PR and VI Payer policies and prior authorization for L5841 26 of 26 payer prior-auth lists that name L5841 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), CarePlus Health Plans, Humana, Medicare, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Passport by Molina Healthcare (Kentucky).
Payer Plan State Prior auth Conditions Since Source Blue Cross Blue Shield of Arizona (AZ Blue) AZ Blue-administered Medicare Advantage (M2K) AZ prior auth required Sep 1, 2026 AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) Blue Cross Blue Shield of Arizona (AZ Blue) Standard PA code list (most commercial plans) AZ prior auth required Sep 1, 2026 AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) Blue Cross Blue Shield of Arizona (AZ Blue) State of Arizona employee group (SYD, S3Z) AZ prior auth required Sep 1, 2026 State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) 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 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 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 Molina Complete Care (Virginia) Medicaid VA prior auth required Apr 1, 2025 Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 Molina Healthcare of California Medicaid CA prior auth required Apr 1, 2026 Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 Molina Healthcare of Idaho Medicaid ID prior auth required Jan 1, 2025 Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 Molina Healthcare of Illinois Medicaid IL prior auth required Jul 1, 2024 Molina Healthcare of Illinois Codification Grid Q3 2026 Molina Healthcare of Michigan Medicare Advantage MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of Michigan Medicaid MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of Mississippi Medicaid MS prior auth required Jan 1, 2025 Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 Molina Healthcare of New Mexico Medicaid NM prior auth required Jul 1, 2026 New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 Molina Healthcare of Texas STAR TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 Molina Healthcare of Texas STAR+PLUS TX prior auth required Feb 19, 2025 Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 Molina Healthcare of Texas STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) TX prior auth required Jul 1, 2024 Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 Passport by Molina Healthcare (Kentucky) Medicaid KY prior auth required Jul 1, 2026 Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Payer coverage policies that name L5841 L5841 appears in 5 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence.
Payer Policy Role in policy Reviewed Document Aetna Lower Limb Prostheses (0578) not covered Oct 9, 2026 payer document Anthem Lower Limb Prosthesis (CG-OR-PR-12)Specific Additions, Knees, Ankles/Feet covered if criteria are met (range L5828-L5841) Aug 13, 2026 payer document Blue Cross & Blue Shield of Mississippi Prosthetics (L.1.04.401) covered if criteria are met 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 Regence Definitive Lower Limb Prostheses (Durable Medical Equipment 18) listed, no stance Dec 1, 2025 payer document
Recent prior-auth changes Jan 1, 2026: PA added, Molina Healthcare of Michigan Feb 19, 2025: PA added, Molina Healthcare of Texas Feb 19, 2025: PA added, Molina Healthcare of Texas Jan 1, 2025: PA added, Molina Healthcare of Texas Jul 1, 2024: PA added, Molina Complete Care (Virginia) Jul 1, 2024: PA added, Molina Healthcare of Michigan Jul 1, 2024: PA added, Molina Healthcare of Mississippi Jul 1, 2024: PA added, Molina Healthcare of Illinois Apr 26, 2024: PA added, humana:pa:commercial Medicaid fee-for-service Prior authorization required or conditional in CO, IN, MS, NE, OH, VA.
AZ: $3555.03 (dme), effective Oct 1, 2026 CO: $2431.27 (health_first_colorado), effective Jul 1, 2026 IN: $2345.31 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $2507.21 (default), effective Jul 1, 2026 MS: $2296.38 (comprehensive), effective Jul 1, 2026 OH: $1465.00 (dme), effective Apr 1, 2024 OK: $2210.37 (dme), effective Jan 1, 2026 TX: $3023.20 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Mar 1, 2025 VT: $2960.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 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.