L3250, Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe,
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.
- No explicit covered indications/diagnoses/clinical scenarios are provided in the supplied document excerpt.
- Replacement of a missing body part (prosthesis), including arms, breasts, ears, feet, hands, legs and maxillofacial (jaw and face).
- Lower limb prostheses designed to replace portions of the lower extremity to improve function.
5 Active Policies
HUMANA-PROSTHETICS-OK-MEDICAID, Prosthetics
HUMANA-PROSTHETICS-KY-MEDICAID, Prosthetics
HUMANA-PROSTHETICS-SC-MEDICAID, Prosthetics
ANTHEM-CG-DME-20, CG-DME-20 Orthopedic Footwear
L33641, Orthopedic Footwear
Related Codes
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