L7700 Pros soc insert gasket/sealGasket or seal, for use with prosthetic socket insert, any type, each
18 of 20 payer prior-auth lists that name L7700 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid).
| 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 | |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 | |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 |
L7700 appears in 13 coverage policies from Blue Cross & Blue Shield of Mississippi, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | 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 |
| UnitedHealthcare | Lower Extremity Prosthetics (CS361.H) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Lower Extremity Prosthetics (2026T0645N) | 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 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 |
Prior authorization required or conditional in IL, NY, OH, 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.