L3204 — Orthopedic shoe, hightop with supinator or pronator, infant
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS items that require a WOPD, the supplier must have received a signed SWO/WOPD before delivery.
- For DMEPOS base items that require a WOPD and also have separately billed options/accessories/supplies, the WOPD must list the base item and may list the separately billed associated items prior to delivery.
- Suppliers are required to maintain proof of delivery documentation and make POD available to the Medicare contractor upon request.
- Suppliers must follow the LCD-related Standard Documentation Requirements Article, the LCD-related Policy Article, the Supplier Manual, and DME MAC publications for additional documentation and payment rules.
Key Coverage Criteria
- An item is covered only if it is an eligible Medicare benefit category, is reasonable and necessary for diagnosis or treatment or to improve functioning of a malformed body member, and meets all Medicare statutory and regulatory requirements.
- Prosthetic shoes (HCPCS L3250) are covered when they are an integral part of a prosthesis for a beneficiary with a partial foot amputation.
- An item that is correctly coded in accordance with CMS HCPCS guidelines, applicable LCDs, LCD-related Policy Articles, and DME MAC articles meets a necessary coding requirement for coverage.
1 Active Policy
L33641 — Orthopedic Footwear
J19
Related Codes
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