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
HCPCS Level II L-code · short descriptor: “Sio flex pelvic/sacr pre ots”
- Code system
- HCPCS Level II
- Family
- L — Orthotics & prosthetics
- Medicare coverage status
- Carrier judgment — coverage decided by the DME MAC
- DMEPOS payment category
- Prosthetics & orthotics
- Prior authorization
- Not on Medicare required-PA list
- Status
- Active (April 2026 HCPCS)
Prior authorization
Not on the Medicare required-PA list as of the January 13, 2026 update (74 items). Medicare Advantage and commercial plans set their own prior-authorization rules for this code — verify per plan before delivery.
L0621 Medicare fee schedule (April 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $33.70 to $127.41 depending on state and rural status.
| State | Non-rural | Rural |
|---|---|---|
| AK | $122.63 | — |
| AL | $76.50 | $93.34 |
| AR | $76.50 | $95.64 |
| AZ | $72.14 | $108.89 |
| CA | $33.70 | $108.89 |
| CO | $50.21 | $103.80 |
| CT | $76.50 | $100.32 |
| DC | $67.12 | $91.23 |
| DE | $67.12 | $91.23 |
| FL | $76.50 | $93.34 |
| GA | $76.50 | $93.34 |
| HI | $127.41 | — |
| IA | $75.00 | $107.38 |
| ID | $50.21 | $107.68 |
| IL | $64.94 | $91.23 |
| IN | $64.94 | $91.23 |
| KS | $75.00 | $107.38 |
| KY | $76.50 | $93.34 |
| LA | $76.50 | $95.64 |
| MA | $76.50 | $100.32 |
| MD | $67.12 | $91.23 |
| ME | $76.50 | $100.32 |
| MI | $64.94 | $91.23 |
| MN | $75.00 | $91.23 |
| MO | $75.00 | $107.38 |
| MS | $76.50 | $93.34 |
| MT | $50.21 | $103.80 |
| NC | $76.50 | $93.34 |
| ND | $75.00 | $103.80 |
| NE | $75.00 | $107.38 |
| NH | $76.50 | $100.32 |
| NJ | $67.12 | $93.83 |
| NM | $72.14 | $95.64 |
| NV | $33.70 | $108.89 |
| NY | $67.12 | $93.83 |
| OH | $64.94 | $91.23 |
| OK | $72.14 | $95.64 |
| OR | $33.70 | $107.68 |
| PA | $67.12 | $91.23 |
| PR | $109.65 | — |
| RI | $76.50 | $100.32 |
| SC | $76.50 | $93.34 |
| SD | $75.00 | $103.80 |
| TN | $76.50 | $93.34 |
| TX | $72.14 | $95.64 |
| UT | $50.21 | $103.80 |
| VA | $76.50 | $91.23 |
| VI | $109.08 | — |
| VT | $76.50 | $100.32 |
| WA | $33.70 | $107.68 |
| WI | $64.94 | $91.23 |
| WV | $76.50 | $91.23 |
| WY | $50.21 | $103.80 |
Amounts are the Medicare DMEPOS fee-schedule allowables effective April 2026.
Medicare typically pays 80% of the allowable after the Part B deductible; the patient owes 20%.
A 2% sequestration reduction applies to the Medicare share. Former competitive-bidding-area
adjustments and non-continental rates can differ — verify with your DME MAC.
Common denial codes to watch
Related L-codes
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