L4090 — Replace metal bands kafo-afo, calf or distal thigh
HCPCS Level II L-code · short descriptor: “Repl met band kafo-afo calf/”
- 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.
L4090 Medicare fee schedule (April 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $103.77 to $142.76 depending on state and rural status.
Former-CBA payment limits: ceiling $138.37 · floor $103.77
| State | Non-rural | Rural |
|---|---|---|
| AK | $122.52 | — |
| AL | $108.72 | — |
| AR | $131.28 | — |
| AZ | $126.49 | — |
| CA | $126.49 | — |
| CO | $103.77 | — |
| CT | $120.73 | — |
| DC | $104.67 | — |
| DE | $104.67 | — |
| FL | $108.72 | — |
| GA | $108.72 | — |
| HI | $131.01 | — |
| IA | $133.07 | — |
| ID | $138.25 | — |
| IL | $103.88 | — |
| IN | $103.88 | — |
| KS | $133.07 | — |
| KY | $108.72 | — |
| LA | $131.28 | — |
| MA | $120.73 | — |
| MD | $104.67 | — |
| ME | $120.73 | — |
| MI | $103.88 | — |
| MN | $103.88 | — |
| MO | $133.07 | — |
| MS | $108.72 | — |
| MT | $103.77 | — |
| NC | $108.72 | — |
| ND | $103.77 | — |
| NE | $133.07 | — |
| NH | $120.73 | — |
| NJ | $123.50 | — |
| NM | $131.28 | — |
| NV | $126.49 | — |
| NY | $123.50 | — |
| OH | $103.88 | — |
| OK | $131.28 | — |
| OR | $138.25 | — |
| PA | $104.67 | — |
| PR | $142.76 | — |
| RI | $120.73 | — |
| SC | $108.72 | — |
| SD | $103.77 | — |
| TN | $108.72 | — |
| TX | $131.28 | — |
| UT | $103.77 | — |
| VA | $104.67 | — |
| VI | $123.50 | — |
| VT | $120.73 | — |
| WA | $138.25 | — |
| WI | $103.88 | — |
| WV | $104.67 | — |
| WY | $103.77 | — |
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
Bill L4090 with confidence
MyMedi-AI scrubs whole claims against NCCI pairs, MUE limits, modifier rules, and PA flags before you submit — built for DME teams, no PHI stored on our servers.
Start free trial Run a CMS-0057-F readiness checkPrefer DIY compliance? Self-audit documentation kits for DME suppliers →