HCPCS Level II › Q codes Q4021 Cast sup sht arm splint plstCast supplies, short arm splint, adult (11 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: Clinical: Data Outpatient hospital: max 2 units per day (clinical), rationale: Clinical: Data DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for Q4021 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, splints and casts (SC): non-rural $8.59 in the contiguous states; $8.59 in AK, HI, PR and VI; ceiling $8.59, floor $7.30 Physician Fee Schedule (CY 2026, RVU26D) Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for Q4021 Payer coverage policies that name Q4021 Q4021 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: $10.25 (dme), effective Oct 1, 2026 CO: $7.02 (chp_plus, non-facility), effective Jul 1, 2026 FL: $3.93 (physician, non-facility), effective Jan 1, 2026 IN: $7.16 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 MS: $6.87 (comprehensive), effective Jul 1, 2026 ND: $8.19 (physician), effective Aug 1, 2026 OH: $6.73 (dme), effective Jan 1, 2026 OK: $8.59 (dme), effective Jan 1, 2026 VT: $7.20 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $8.59 (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.