L4055 — Replace non-molded calf lacer, for custom fabricated orthosis only
HCPCS Level II L-code · short descriptor: “Replace non-molded calf lace”
- 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.
L4055 Medicare fee schedule (April 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $307.20 to $686.22 depending on state and rural status.
Former-CBA payment limits: ceiling $409.60 · floor $307.20
| State | Non-rural | Rural |
|---|---|---|
| AK | $641.79 | — |
| AL | $307.20 | — |
| AR | $312.94 | — |
| AZ | $409.60 | — |
| CA | $409.60 | — |
| CO | $307.20 | — |
| CT | $409.60 | — |
| DC | $307.20 | — |
| DE | $307.20 | — |
| FL | $307.20 | — |
| GA | $307.20 | — |
| HI | $686.22 | — |
| IA | $328.46 | — |
| ID | $311.64 | — |
| IL | $307.20 | — |
| IN | $307.20 | — |
| KS | $328.46 | — |
| KY | $307.20 | — |
| LA | $312.94 | — |
| MA | $409.60 | — |
| MD | $307.20 | — |
| ME | $409.60 | — |
| MI | $307.20 | — |
| MN | $307.20 | — |
| MO | $328.46 | — |
| MS | $307.20 | — |
| MT | $307.20 | — |
| NC | $307.20 | — |
| ND | $307.20 | — |
| NE | $328.46 | — |
| NH | $409.60 | — |
| NJ | $307.20 | — |
| NM | $312.94 | — |
| NV | $409.60 | — |
| NY | $307.20 | — |
| OH | $307.20 | — |
| OK | $312.94 | — |
| OR | $311.64 | — |
| PA | $307.20 | — |
| PR | $523.52 | — |
| RI | $409.60 | — |
| SC | $307.20 | — |
| SD | $307.20 | — |
| TN | $307.20 | — |
| TX | $312.94 | — |
| UT | $307.20 | — |
| VA | $307.20 | — |
| VI | $307.20 | — |
| VT | $409.60 | — |
| WA | $311.64 | — |
| WI | $307.20 | — |
| WV | $307.20 | — |
| WY | $307.20 | — |
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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