L1904 — Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated
L1904 is a HCPCS Level II code for ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated. It belongs to the Orthotic and Prosthetic Procedures and Devices section. Whether Medicare pays it depends on the coverage rule below.
Medicare coverage: Carrier judgment
Coverage is decided by your Medicare contractor, not by national policy. Whether this is paid depends on the LCD for your jurisdiction and on what the documentation supports.
From the coverage field of the CMS Alpha-Numeric HCPCS File, release 2026Q3-Jul. This states Medicare’s position on the code, not on your particular claim.
Medically Unlikely Edits — units per day
The most units of L1904 Medicare will pay on one date of service. Bill more on a single line and it is denied. The limit is not the same in every setting, so the row that matters is the one matching the claim you are building.
- practitioner
- 0 — never payable MAI 3 — Date of Service Edit: Clinical · CMS Policy
- outpatient
- 2 units MAI 2 — Date of Service Edit: Policy · Anatomic Consideration
- DME supplier
- 2 units MAI 2 — Date of Service Edit: Policy · Anatomic Consideration
The adjudication indicator decides whether exceeding the limit is worth appealing at all: MAI 1 is a line edit you can support with documentation, MAI 3 is a date-of-service edit that is also appealable, and MAI 2 is absolute — no documentation overrides it. CMS MUE 2026Q3.
The CMS record for L1904
- Long descriptor
- Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated
- Short descriptor
- Afo molded ankle gauntlet
- Added
- January 1, 1988
- BETOS
- D1F
- Pricing indicator
- 38 — DMEPOS
The official wording. This is what the code means.
CMS's 28-character form, which is what shows up on a remittance advice.
When CMS introduced the code.
Berenson-Eggers Type of Service — CMS's own analytic grouping.
Orthotics, prosthetics, prosthetic devices and vision services. Price subject to floors and ceilings.
Codes adjacent to L1904
HCPCS has no hierarchy — related items simply sit next to each other in the numbering. If L1904 is not quite right, the correct code is very often within a few positions of it.
- L1847Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L1848Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf
- L1850Knee orthosis, swedish type, prefabricated, off-the-shelf
- L1851Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
- L1852Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
- L1860Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk)
- L1900Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated
- L1902Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf
- L1906Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf
- L1907Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated
- L1910Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment
- L1920Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated
- L1930Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment
- L1932Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
- L1933Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf
- L1940Ankle foot orthosis, plastic or other material, custom fabricated
Questions about L1904
What is HCPCS code L1904?
L1904 is a HCPCS Level II code for ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated. It sits in the Orthotic and Prosthetic Procedures and Devices section.
Does Medicare cover L1904?
The CMS HCPCS file marks L1904 as "Carrier judgment". Coverage is decided by your Medicare contractor, not by national policy. Whether this is paid depends on the LCD for your jurisdiction and on what the documentation supports.