L5704 — Custom shaped protective cover, below knee

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

Face-to-face & WOPD

Not on the required list

MUE unit limit

2

Status

Active (HCPCS Level II October 2026)

Every Medicare DMEPOS claim needs a Standard Written Order with all six elements (42 CFR 410.38(d)):

• Beneficiary name or Medicare Beneficiary Identifier (MBI) (42 CFR 410.38(d)(1)(i)(A))
• General description of the item (42 CFR 410.38(d)(1)(i)(B))
• Quantity to be dispensed, if applicable (42 CFR 410.38(d)(1)(i)(C))
• Order date (42 CFR 410.38(d)(1)(i)(D))
• Treating practitioner name or NPI (42 CFR 410.38(d)(1)(i)(E))
• Treating practitioner signature (42 CFR 410.38(d)(1)(i)(F))

Not on the F2F/WOPD list (CMS Required F2F & WOPD List — 83 items in force on 2026-10-25; 22 more from 2026-10-28; sources: CMS list effective 2026-04-13 (91 FR 1250), CMS-6109-N (91 FR 47972)). The standard written order must reach the supplier before claim submission.

Blank requirements checklist only — MyMedi-AI never collects or stores completed orders.