Draftpriority healthPolicy N/A

PROSTHETICS, ORTHOTICS AND FOOTWEAR

Governs payment, billing, coding, modifier use, documentation and frequency limits for prosthetic, orthotic and therapeutic footwear items and supplies furnished to Priority Health members.

Policy Summary

Payerpriority health

PolicyProsthetics, Orthotics and Footwear reimbursement and documentation requirements

Policy CodePolicy N/A

Change TypeMultiple additions and frequency-limit revisions

Effective DateN/A

Next Review DateN/A

Key ActionFollow CMS Article A55426 standard documentation requirements for supplies and DME claims submitted to DME MACs.

SourceLink

POLICY UPDATE CHANGES

Added 'Frequency limits' section, in alignment with MDHHS guidelines; Limits will be effective Aug. 25, 2025.

Added 'Facial prosthesis' and 'Ocular prosthesis' sections. Changes effective 11/17/2025.

Added 'Spinal Orthoses' section.

Added 'Disclaimer' section.

Added modifier CG to the modifiers section.

June 19, 2025 revisions aligned frequency limits with MDHHS guidelines.

CMS alignmentDocumentation requirements reference CMS Article A55426

2025-08-25frequency limits effective date noted

90 daysTime threshold for separate facial prosthesis mods

2/year

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage, Bundling and Frequency Rules

Coding/unbundling/bundling rules

Coding, unbundling and add-on rules for footwear, orthoses and prostheses. Use the HCPCS/L-code that accurately describes the product and level of fitting. Do not report corresponding Column I and Column II codes together; miscellaneous/unlisted codes require explanatory notes. Addition/component codes listed as 'not separately payable' are bundled into the base orthosis or prosthesis allowance.

Use the single HCPCS/L code that accurately represents both the orthosis/prosthesis type and level of fitting provided; maintain supplier documentation that substantiates the selected code. (Source: Spinal Orthoses guidance)

Prefabricated vs. prefabricated-customized: use the prefabricated off‑the‑shelf HCPCS when only minimal self-adjustment occurred; use the prefabricated‑customized HCPCS when trimming/bending/molding/assembly by qualified personnel was performed. (Source: chunk 11)

When billing miscellaneous/unlisted HCPCS (e.g., L2999, L3649, L5999), include explanatory notes on the claim describing the item and why an unlisted code is used; L2999 is the miscellaneous code for AFOs/KAFOs. (Source: chunk 5, chunk 4, chunk 6)

Do not report HCPCS codes from Column I and Column II in the same row together — they represent identical products differentiated only by level of fitting. Reporting both is incorrect and will be treated as unbundling. (Source: chunk 5, chunk 7)

Addition/component codes that are listed as 'not separately payable' for specific base orthosis codes are included in the allowance for that orthosis and must not be billed separately unless the base orthosis code is paid. Examples: L4631 includes all additions; L4360/L4361/L4386/L4387 are complete prefabricated walking boots — add‑on codes reported with these will be unbundled; extensive lists of knee orthosis base codes have specified non‑payable addition codes (e.g., L1810 additions include L2390, L2750, L2780, L4002). (Source: chunk 5, chunk 8, chunk 9, chunk 10, chunk 6)

Lower limb prosthesis coding: do not use L5999 to bill for features or functions already included in the socket or addition codes; use of L5999 in that manner is unbundling. Labor for replacement parts included in specific HCPCS is not payable separately (e.g., labor is included; do not bill L7520 for labor when a specific code exists). (Source: chunk 6)

Orthopedic footwear/diabetic shoes: use A5500/A5501 for diabetic shoes and the A55xx insert/modification codes (A5503–A5514, A5510, A5512–A5514) only for items related to diabetic shoes. Inserts/modifications used with L‑coded footwear must be coded with L codes — do not use A‑codes with L‑coded footwear. Oxford shoes integral to a brace billed with L3224/L3225 (per shoe); non‑integral Oxford shoes billed with L3215/L3219. Other integral shoes use L3649 (with explanatory notes); non‑integral footwear use the specified L‑codes (L3216, L3217, L3221, L3222, L3230, L3251–L3253, etc.). Inserts/modifications for diabetic shoes (A55xx) should not be used for non‑diabetic L‑coded footwear. (Source: chunk 4, chunk 19, chunk 22)

Claims for Column II items billed with the provision of a Column I item will be denied as unbundling; payments for Column II items are included in the payment for the Column I code or vice versa per the column mapping. (Source: chunk 6)

Facial and ocular prostheses: supplies (adhesives, removers, skin barrier wipes, tape) used with facial prostheses are eligible; facial prostheses provided inpatient are bundled into the hospital payment and must not be billed separately. Modifications performed >90 days after delivery for documented change are separately payable; modifications, repairs, materials, labor, fitting, and follow‑up within 90 days are included in the allowance and not separately billable. Ocular component billing: V2623/V2629 billed separately when new and part of facial prosthesis; reused ocular components should not be billed separately. Polishing/resurfacing (V2624) covered twice per calendar year; one enlargement (V2625) or reduction (V2626) covered without documentation. Modifiers such as KX (commercial/Medicaid) and KX/GA/GY/GZ (per LCDs for Medicare) may be required per applicable guidance. (Source: chunk 13, chunk 15)

Append the appropriate laterality modifiers (LT/RT) and adhere to HCPCS frequency/modifier rules — many L and A codes have specified frequency limits when billed with LT/RT (see HCPCS modifiers frequency list). Failure to adhere to modifier/frequency rules may result in denials or recoupment. (Source: chunks 19–27)

Codes, Modifiers and Frequency Tables

Footwear and insert coding rulesHCPCSCovered

L3224 / L3225	Oxford shoes integral to a brace; one unit per shoe
L3215 / L3219	Oxford shoes not part of a leg brace
L3649	Other shoes integral to a brace (unlisted/not otherwise specified — include explanatory notes)
A5503-A5514	Codes for inserts or modifications related to diabetic shoes (use with A5500/A5501)

Orthosis and prosthesis coding and bundlingHCPCSCovered

L2999	Miscellaneous HCPCS for AFOs/KAFOs — require explanatory notes
L4360/L4361/L4386/L4387	Prefabricated walking boots described as complete products; add-on codes unbundled
Various Column I / Column II pairs	Corresponding HCPCS code sets represent identical products and should not be reported together

Adhesive items requiring AV modifierHCPCSCovered

A4450	Adhesive-related item (requires AV modifier)
A4452	Adhesive-related item (requires AV modifier)
A5120	Adhesive-related item (requires AV modifier)

Footwear/orthotic/prosthetic HCPCS codes with frequency limitsHCPCSCovered

L0120 - L6999 (representative range)

Various L and other HCPCS codes with specified per-period frequency limits and laterality modifiers

Frequency limits per side / year — modifier-specific rules

A5503–A55061 Per Year with Modifier LT; 1 Per Year with Modifier RT = 1 Per 6 Months with Modifier LT; 1 Per 6 Months with Modifier RT.

A5510, A5512–A55141 Per Year with Modifier LT; 1 Per Year with Modifier RT = 3 Per Year with Modifier LT; 3 Per Year with Modifier RT.

L0120–L0200 series1 Per Year with Modifier LT; 1 Per Year with Modifier RT = 1 Per Year.

L0450–L0492 and L0621–L0648 series1 Per Year with Modifier LT; 1 Per Year with Modifier RT = 1 Per 1 Year.

L0970–L1030 and L1000–L1260 ranges1 Per Year with Modifier LT; 1 Per Year with Modifier RT = 1 Per Year.

Documentation, Authorization and Required Actions

Documentation Required

Follow CMS Article A55426 for DME/supplies documentation

Follow CMS Article A55426 — "Standard Documentation Requirements for All Claims Submitted to DME MACs" — for supplies and DME claims submitted to DME MACs. Documentation must meet CMS standards to support billed services and items.

Use CMS Article A55426 as the documentation standard for supplies and DME.
Ensure medical record documentation fully supports the service/item billed to the highest level of specificity.

Prior Authorization

Obtain authorization and document medical necessity

Obtain and document any required authorizations and ensure medical necessity is established for the procedure, diagnosis and frequency billed; an authorization is not a guarantee of payment if billing/coding or policy requirements are not met.

Authorization and medical necessity appropriate to procedure, diagnosis and frequency are required.

Policy Definitions and Modifier Guidance

Definition / Purpose

ScopeIdentifies payment and documentation requirements for prosthetic, orthotic and footwear items.

IncludesCoverage positions, billing/coding rules, modifier use, documentation and frequency limits.

PurposeProvide guidance to providers on reimbursement and necessary documentation to support claims.

Spinal orthosis coverage definition

Device typeRigid or semi-rigid lumbar-sacral (LSO) and thoracic-lumbar-sacral (TLSO) orthoses.

Coverage criterionOrthosis must be intended to support a weakened or deformed body part, or to restrict/prevent movement in an injured or diseased area.