`L8658` Interphalangeal joint spacer

Interphalangeal joint spacer, silicone or equal, each

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 2 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 3 units per day (clinical), rationale: Clinical: CMS Workgroup
DME supplier: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for L8658

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, prosthetics and orthotics (PO): non-rural $373.64 to $498.19 in the contiguous states; ceiling $498.19, floor $373.64

Payer policies and prior authorization for L8658

1 of 1 payer prior-auth lists that name L8658 require prior authorization or set conditions: Rocky Mountain Health Plans.

Payer	Plan	State	Prior auth	Conditions	Since	Source
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 L8658

L8658 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants (0798)	covered if criteria are met	Feb 24, 2026	payer document
Aetna	Metatarsal Phalangeal Joint Replacement (0708)	listed, no stance	Nov 24, 2025	payer document
Aetna	Skin and Soft Tissue Substitutes (0244)	not covered	Jul 29, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Pyrocarbon Metacarpophalangeal And Proximal Interphalangeal Joint Implants (L.7.01.411)	unproven / investigational		payer document

Medicaid fee-for-service

Prior authorization required or conditional in OH, VA.

AZ: $347.82 (dme), effective Oct 1, 2026
CO: $384.51 (chp_plus, non-facility), effective Jul 1, 2026
IN: $311.37 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
MD: $342.65 (dme), effective Apr 1, 2026
OH: $390.73 (dme), effective Jan 1, 2026
OK: $261.55 (dme), effective Jan 1, 2026
VA: $303.85 (medical), effective Jan 1, 2012
VT: $0.00 (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.

L8658 Interphalangeal joint spacer