L5694 — Addition to lower extremity, above knee, pelvic control belt, padded and lined
HCPCS Level II L-code · short descriptor: “Ak pelvic control belt pad/l”
- 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.
L5694 Medicare fee schedule (April 2026)
Base (no modifier) Prosthetics & orthotics
Medicare allowable ranges from $222.10 to $375.97 depending on state and rural status.
Former-CBA payment limits: ceiling $296.13 · floor $222.10
| State | Non-rural | Rural |
|---|---|---|
| AK | $351.61 | — |
| AL | $222.10 | — |
| AR | $296.13 | — |
| AZ | $296.13 | — |
| CA | $296.13 | — |
| CO | $247.59 | — |
| CT | $296.13 | — |
| DC | $222.10 | — |
| DE | $222.10 | — |
| FL | $222.10 | — |
| GA | $222.10 | — |
| HI | $375.97 | — |
| IA | $222.10 | — |
| ID | $294.97 | — |
| IL | $222.10 | — |
| IN | $222.10 | — |
| KS | $222.10 | — |
| KY | $222.10 | — |
| LA | $296.13 | — |
| MA | $296.13 | — |
| MD | $222.10 | — |
| ME | $296.13 | — |
| MI | $222.10 | — |
| MN | $222.10 | — |
| MO | $222.10 | — |
| MS | $222.10 | — |
| MT | $247.59 | — |
| NC | $222.10 | — |
| ND | $247.59 | — |
| NE | $222.10 | — |
| NH | $296.13 | — |
| NJ | $222.10 | — |
| NM | $296.13 | — |
| NV | $296.13 | — |
| NY | $222.10 | — |
| OH | $222.10 | — |
| OK | $296.13 | — |
| OR | $294.97 | — |
| PA | $222.10 | — |
| PR | $243.90 | — |
| RI | $296.13 | — |
| SC | $222.10 | — |
| SD | $247.59 | — |
| TN | $222.10 | — |
| TX | $296.13 | — |
| UT | $247.59 | — |
| VA | $222.10 | — |
| VI | $222.10 | — |
| VT | $296.13 | — |
| WA | $294.97 | — |
| WI | $222.10 | — |
| WV | $222.10 | — |
| WY | $247.59 | — |
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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