Does L3649 require prior authorization?

Yes, L3649 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`L3649`, Orthopedic shoe, modification, addition or transfer, not otherwise specified

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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.

ICD-10 diagnosis codes required for coverage of prosthetic shoes are specified in the LCD-related Policy Article and must be documented per that related article.

No specific documentation requirements are stated in this Clinical Policy Bulletin.

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.
None — Aetna considers pedobarography (foot pressure studies) experimental and investigational and does not identify any covered indications.

4 Active Policies

ANTHEM-CG-DME-53, Biomechanical Footwear Therapy

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33641, Orthopedic Footwear

AETNA-CPB-0294, Pedobarography

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L3649, Orthopedic shoe, modification, addition or transfer, not otherwise specified