Preauthorization Requirements –
Effective Aug. 13, 2026

A4318

Female external urinary collection cup, with or without ring attachment, per day

A4479

Electronic transanal irrigation system, includes electronic pump, water reservoir, tubing, and accessories, without catheter, any type

A6548

Accessory to custom gradient compression garment, silicone band, any size

A8005

Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted

A8006

Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only

L2221

Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source

L5992

All lower extremity prosthesis, foot shell for modular foot/nonsolid ankle cushion heel (SACH) replacement only