Effective Date: April 1, 2026

Health Plans Affected: Priority Partners

Type of Change: DME Codes Authorization Requirements Status

Explanation of Change:
Please note that the following DME codes for Priority Partners have changed from Not Covered to Covered, retroactively effective to April 1, 2026, due to an update in the MDH fee schedule:

KEY: PA = Prior Authorization Required; NPA = No Prior Authorization Required

• A4318 - Fem urinary cup w/wo attachment;   NPA
• A4479 - Electro pump enema, reusable;   NPA
• A6548 - Acces custom gradient silicone band;  NPA
• A6583 - Gradient com wrap w straps bk;   NPA
• L2221 - Ankle mcrop plant & dorsi flex;   PA
• L5657 - Add low ext man aut vol any;   NPA
• L5992 - Low prosth foot shell repl;    NPA
• L6028 - Part hand finger metacar amp;   PA
• L6029 - Test interface part handfing;   NPA
• L6030 - External frame part handfing;    NPA
• L6031 - Rep interface handfng molded;   PA
• L6032 - Part handfng ultralite tcf/=;    NPA
• L6033 - Part handfing acrylic;    NPA
• L6034 - Part hand finger distal amp;    NPA
• L6035 - Prosthetic digit mechanical;    PA
• L6036 - Prosthetic thumb mechanical;   PA
• L6037 - Postop dsg cast chg handfing;   NPA
• L6038 - Multiax rotation attachment;    NPA
• L6039 - Passive custom digit/thumb;    PA

Prior Authorization Process

Please use our secure online portal, Availity, to submit electronic prior authorization requests.