HCPCS Level II › Q codes Q4015 Cast sup gauntlet ped plsterCast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 2 units per day (clinical), rationale: Anatomic Consideration Outpatient hospital: max 2 units per day (clinical), rationale: Anatomic Consideration DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for Q4015 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, splints and casts (SC): non-rural $10.05 in the contiguous states; $10.05 in AK, HI, PR and VI; ceiling $10.05, floor $8.54 Physician Fee Schedule (CY 2026, RVU26D) Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for Q4015 Payer coverage policies that name Q4015 Q4015 appears in 2 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Bone and Tendon Graft Substitutes and Adjuncts (0411) listed, no stance (range Q4001-Q4048) Aug 18, 2026 payer document Aetna Orthopedic Casts, Braces and Splints (0009) covered if criteria are met (range Q4001-Q4051) Jan 20, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in OH.
AZ: $11.99 (dme), effective Oct 1, 2026 CO: $8.20 (chp_plus, non-facility), effective Jul 1, 2026 FL: $4.59 (physician, non-facility), effective Jan 1, 2026 IN: $8.37 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 MS: $8.04 (comprehensive), effective Jul 1, 2026 ND: $9.57 (physician), effective Aug 1, 2026 OH: $7.88 (dme), effective Jan 1, 2026 OK: $10.05 (dme), effective Jan 1, 2026 VT: $8.42 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $10.05 (physician, facility), effective Jul 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.