L8417 Pros sheath/sock w gel cushn

Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each

Medically Unlikely Edits (effective October 1, 2026)

Medicare pricing for L8417

DMEPOS fee schedule, July 2026 (DME26-C)

Payer policies and prior authorization for L8417

Payer coverage policies that name L8417

L8417 appears in 15 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaLower Limb Prostheses (0578)covered if criteria are metOct 9, 2026payer document
AnthemLower Limb Prosthesis (CG-OR-PR-12)
Other Specific Accessories		covered if criteria are met (range L8417-L8430)Aug 13, 2026payer document
Blue Cross & Blue Shield of MississippiProsthetics (L.1.04.401)covered if criteria are metpayer 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 stanceJan 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (CS361.H)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (2026T0645N)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Idaho Only) (CS361ID.F)listed, no stanceSep 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Kansas Only) (CS361KS.05)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Kentucky Only) (CS361KY.07)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Nebraska Only) (CS361NE.G)listed, no stanceSep 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for New Jersey Only) (CS361NJ.H)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for New Mexico Only) (CS361NM.F)listed, no stanceAug 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Ohio Only) (CS361OH.F)listed, no stanceApr 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Pennsylvania Only) (CS361PA.G)listed, no stanceSep 1, 2026payer document
UnitedHealthcareLower Extremity Prosthetics (for Tennessee Only) (CS361TN.H)listed, no stanceSep 1, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in LA, MA, MS, NY, VA, WV.

  • AZ: $84.14 (dme), effective Oct 1, 2026
  • CO: $64.23 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $47.75 (dme), effective Jul 1, 2026
  • IN: $77.18 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
  • KS: $55.29 (default, Mid Level Practitioner), effective Jul 1, 2026
  • KY: $58.17 (dme), effective Jan 1, 2026
  • LA: $50.53 (dme), effective Jul 1, 2012
  • MA: $69.06 (orthotics_prosthetics_rates), effective Apr 1, 2024
  • MD: $76.77 (dme), effective Apr 1, 2026
  • MS: $74.48 (comprehensive), effective Jul 1, 2026
  • ND: $0.00 (dme), effective Aug 1, 2026
  • NE: $79.12 (dme), effective Jul 1, 2026
  • NY: $32.12 (dme), effective Jul 1, 2026
  • OH: $48.14 (dme), effective Jan 1, 2010
  • OK: $65.16 (dme), effective Jan 1, 2026
  • TX: $55.89 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Feb 1, 1997
  • VA: $68.06 (medical), effective Jan 1, 2012
  • VT: $75.65 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $67.93 (prosthetics_orthotics), effective Jul 1, 2026
  • WY: $59.79 (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.