Prior-Authorization HCPCS Code List for Healthfirst Plans
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This document lists Healthcare Common Procedure Codes (HCPC) that must be used when submitting prior-authorization requests for Healthfirst health plans; it affects providers submitting PA requests for durable medical equipment, supplies, enteral/parenteral nutrition, respiratory equipment, wheelchairs, and related items.
No material clinical or coverage changes in this revision.
Prior-authorization coverage criteria and code requirements
Prior-authorization code requirements
List of HCPCS codes that require prior-authorization for Healthfirst plans. Providers must use these codes when submitting PA requests.
Prior-authorization requirements (code list)
Codes listed in this prior-authorization section require prior authorization before payment; the list includes E- and K- series HCPCS codes for wheelchairs, accessories, respiratory equipment, DME, and related items.
Examples (selected from list)
- E1239 — Power wheelchair, pediatric size (Product Category = Wheelchairs and Accessories).
- E1240 — Lightweight wheelchair, detachable arms (Product Category = Wheelchairs and Accessories).
- E1250 — Lightweight wheelchair, fixed full length arms (Product Category = Wheelchairs and Accessories).
- K0006 — Heavy duty wheelchair.
- K0010 — Standard - weight frame motorized/power wheelchair.
- K0011 — Motorized/power wheelchair with programmable control parameters.
Prior authorization requirement - code listing
The following HCPCS codes are included in the prior-authorization list for DME, wheelchairs, power wheelchairs, accessories, and orthotics.
Selected K- and K-related codes
- K0006 — Heavy duty wheelchair.
- K0007 — Extra heavy duty wheelchair.
- K0008 — Custom manual wheelchair/base.
- K0010 — Standard - weight frame motorized/power wheelchair.
- K0011 — Motorized/power wheelchair with programmable control parameters.
- K0037 — High mount flip-up footrest, each.
- K0038 — Leg strap, each.
- K0039 — Leg strap, h style, each.
- K0040 — Adjustable angle footplate, each.
Prior-authorization required codes (orthotics) — list
This excerpt is a prior-authorization code list: the following HCPCS L-codes for orthotic devices and additions are included in the prior-authorization requirement.
Selected orthotic L-codes (sample)
- L0482 — TLSO, triplanar control, one piece rigid plastic shell with interface liner (Product Category = Orthotics).
- L0484 — TLSO, triplanar control, two piece rigid plastic shell without interface liner, custom fabricated (Product Category = Orthotics).
- L0486 — TLSO, triplanar control, two piece rigid plastic shell with interface liner, custom fabricated (Product Category = Orthotics).
- L0488 — TLSO, triplanar control, one piece rigid plastic shell with interface liner, prefabricated, includes fitting and adjustment (Product Category = Orthotics).
- L0621 — Sacroiliac orthosis, flexible, prefabricated, off-the-shelf (Product Category = Orthotics).
- L0626 — Lumbar orthosis, sagittal control, prefabricated item trimmed/adjusted to fit a specific patient (Product Category = Orthotics).
- L0627 — Lumbar orthosis, sagittal control, with rigid anterior and posterior panels (Product Category = Orthotics).
Prior-authorization code listing — Orthotics (partial)
This segment enumerates orthotic HCPCS L-codes that are part of the prior-authorization list.
Lower extremity orthotic additions (selected)
- L2180 — Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints.
- L2184 — Addition to lower extremity fracture orthosis, limited motion knee joint.
- L2186 — Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type.
- L2221 — Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature, includes power source.
- L2232 — Addition to lower extremity orthosis, rocker bottom for total contact AFO, custom fabricated (for custom fabricated orthosis only).
Prior-authorization listing for prosthetics (partial)
This section enumerates HCPCS L-codes for prosthetic devices and additions subject to prior authorization.
Selected prosthetic additions and examples
- L5710 — Addition, exoskeletal knee-shin system, single axis, manual lock.
- L5711 — Addition, exoskeletal knee-shin system, single axis, ultra-light material.
- L5712 — Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee).
- L6689 — Upper extremity addition, frame type socket, shoulder disarticulation.
- L6690 — Upper extremity addition, frame type socket, interscapular-thoracic.
- L6700 — Upper extremity addition, external powered feature, myoelectronic control module (pattern-recognition).
Prior-authorization requirement
Codes requiring prior authorization are enumerated below by HCPCS/L/S/T/V code and description. Providers must seek prior authorization for items listed.
Sample entries from the broader listing
- L6697 — Addition to upper extremity prosthesis, product category = Prosthetics (sample entry).
- L6714 — Terminal device, hand, mechanical, voluntary closing, pediatric (sample entry).
- L6880 — Electric hand, switch or myoelectric controlled, independently articulating digits (sample entry).
- V5264 — Ear mold/insert, not disposable, any type (Product Category = Hearing aids).
Sample code tables and code groups
| A4230 | Infusion set for external insulin pump, non needle cannula type. |
| A4239 | Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service. |
| A4479 | Electronic transanal irrigation system, includes electronic pump, water reservoir, tubing, and accessories, without catheter, any type. |
| B4160 | Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit. |
| B4161 | Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit. |
| B4164 | Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix. |
| K0824 | Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds. |
| K0828 | Power wheelchair, group 2 extra heavy duty, patient weight capacity 601 pounds or more. |
| K0830 | Power wheelchair, group 2 standard, seat elevator, patient weight capacity up to and including 300 pounds. |
| L0482 | Product Category = Orthotics (listed under prior-authorization code list). |
| L0484 | TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, custom fabricated. |
| L0486 | TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, custom fabricated. |
| L0621 | Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf. |
| L0623 | Sacroiliac orthosis, with rigid or semi-rigid panels, prefabricated, off-the-shelf. |
| L0624 | Sacroiliac orthosis, custom fabricated. |
| L0626 | Lumbar orthosis, sagittal control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. |
| L0639 | Lumbar-sacral orthosis, rigid shell(s)/panel(s), prefabricated trimmed/customized. |
| L0974 | TLSO, full corset. |
| L0999 | Addition to spinal orthosis, not otherwise specified. |
| L1000 | CTLSo (Milwaukee), inclusive of furnishing initial orthosis, including model. |
| L1200 | TLSo, inclusive of furnishing initial orthosis only. |
| L1320 | Thoracic, pectus carinatum orthosis, sternal compression, custom fabricated. |
| L3702 | Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment. |
| L3761 | Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf. |
| L3763 | Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment. |
| L3960-L3999 | Orthotic codes covering shoulder/upper limb and other orthoses, includes fitting and adjustment |
| L4002-L4398 | Orthotic accessory and lower extremity orthotic codes including walking boots and AFOs |
| L4631-L5811 | Prosthetic codes covering partial foot through advanced prosthetic systems and additions |
| L5710-L5718, L5722-L5728, L5780-L5795, L5810-L5830, L5840-L5859, L5910-L5999, L6000-L6039, L6050-L6130, L6200-L6360, L6400-L6999 | Range of HCPCS L-codes for prosthetic devices and additions enumerated in this segment (partial list). |
What providers must do when submitting prior-authorization requests
Prior Authorization Required
Prior Authorization Required: Durable medical equipment (DME), wheelchairs, orthotics, prosthetics, and related additions/accessories listed below require prior authorization before submission for Healthfirst plans effective 2026-06-01. Providers must reference the applicable HCPCS (E-, K-, L-, S-, T-, and other) codes when requesting authorization and include supporting clinical documentation per Healthfirst requirements.
- This list is an excerpt and consolidates codes across categories: wheelchairs & accessories (E-/K- series and related K-codes), infusion/respiratory equipment and repair services (K- series), orthotics (L- series), prosthetics and prosthetic additions (L- series), powered/microprocessor features, partial-hand and upper-extremity prosthetics, sockets/disarticulations, preparatory and upper-extremity additions, and terminal devices/accessories.
- Providers must not duplicate requests for items already authorized; replacement, custom fabrication, and powered/microprocessor features commonly require explicit prior authorization.
Prior-authorization required DME codes (excerpt)
Wheelchairs and Accessories (sample requiring prior authorization): E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E1296, E1297; K0006, K0007, K0008, K0010, K0011, K0012, K0014, K0015, K0017, K0018, K0019, K0037, K0038, K0039, K0040, K0072, K0077, K0098, K0105, K0108, K0195, K0455, K0606, K0669, K0733, K0738, K0739, K0899, K0900.
Prior-authorization required Orthotics and misc DME codes
Orthotics and selected miscellaneous DME (sample L-code entries that require prior authorization): L0120, L0130, L0140, L0170, L0172, L0180, L0190, L0200, L0450, L0454, L0456, L0457, L0460, L0482, L0484, L0486, L0488, L0621, L0623, L0624, L0626, L0627, L0628, L0629.
Foot/insert/shoe related orthotics
Foot, insert, and shoe-related orthotics (sample requiring prior authorization): L2180, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2221 (microprocessor-controlled ankle feature with power source), L2230, L2232, L2240, L2999, L3000–L3070, L3080–L3100, L3140–L3170, L3001–L3060 (includes removable molded inserts and premolded arch supports).
Comprehensive prosthetic components, replacements, and system additions
Comprehensive prosthetic components, replacements, and system additions (sample requiring prior authorization): Replacement sockets and custom covers (L5700–L5707), exoskeletal and endoskeletal knee-shin additions (L5710–L5728, L5780), test sockets and preparatory items (L5610–L5638, L5450–L5595, L5500–L5595), numerous replacement and addition codes for sockets, inserts, suspension systems and structural components (L5610–L5699, L5700–L5795, L5910–L5966).
Powered and microprocessor prosthetic features
Powered and microprocessor prosthetic features (sample requiring prior authorization): Microprocessor-controlled knee/shin and ankle-foot features and powered assist additions (L5856–L5859, L5968–L5973, L5973, L5969); powered ankle/foot and microprocessor-controlled endoskeletal features (L5827, L5856–L5859, L5973). These commonly include electronic sensors, power sources, motors, and programmable control and therefore require documentation of functional need and prior approval.
Partial hand and upper extremity prosthetics
Partial hand and upper extremity prosthetics (sample requiring prior authorization): L6000–L6036 (partial hand levels and powered/externally powered options), L6038–L6040 series additions and passive digits (L6039), and early post-surgical fittings (L6037).
Upper extremity sockets and disarticulations
Upper extremity sockets, disarticulations and preparatory systems (sample requiring prior authorization): Replacement and preparatory sockets and disarticulation codes (L6050–L6130, L6200–L6360, L6400–L6570, L6580–L6590, L6680–L6690). Replacement sockets for all levels (L6883–L6885) also require prior authorization.
Preparatory and upper extremity additions
Preparatory and upper-extremity additions (sample requiring prior authorization): Upper extremity addition and accessory codes including polycentric hinges, pivot hinges, suspension sleeves, control cables, harnesses, lift assists, nudge controls, external powered switches and myoelectric controls (L6600–L6677, L6686–L6698, L6611, L6638, L6700). These additions often require documentation of prior prosthetic training, functional goals, and justification for powered or advanced features.
Further upper extremity additions and terminal devices
Further upper-extremity additions and terminal devices (sample requiring prior authorization): Terminal devices and accessories including passive and active hands/hooks, multiple articulating digits, electric/myoelectric hands, precision pinch devices, microprocessor/add-on features, replacement gloves and terminal-device additions (L6703–L6715, L6715, L6721–L6722, L6805, L6810, L6880–L6883, L6890–L6915, L6920).
Unit definitions and terminology
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