HCPCS Code L1904

Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated
Code effective Jan 01, 2016

HCPCS Section
Orthotic and Prosthetic Procedures, Devices

L1904 is a valid 2026 HCPCS code meaning Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated or (Afo molded ankle gauntlet) for short. HCPCS L1904 has been effective since 01/01/2016 and applies to Lump sum purchase of DME, prosthetics, orthotics.

HCPCS Code Details - L1904

HCPCS Level II Code
Section L - Orthotic and Prosthetic Procedures, Devices
HCPCS Code L1904
Description

Long description:
Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated

Short description:
Afo molded ankle gauntlet

HCPCS Pricing indicator 38 - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings)
Multiple pricing indicator A - Not applicable as HCPCS priced under one methodology
Coverage code C - Carrier judgment
BETOS2 code D1F - Prosthetic/Orthotic devices
HCPCS Action code N - No maintenance for this code
Type of service P - Lump sum purchase of DME, prosthetics, orthotics
Effective date Effective Jan 01, 2016
Date added Added Jan 01, 1988

See also

  • HCPCS L1902 · Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

  • HCPCS L1906 · Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf

1 Two-digit numeric codes are Level I code modifiers copyrighted© by the American Medical Association's Current Procedural Terminology (CPT).

2 BETOS stands for “Berenson-Eggers Type Of Service”

HCPCS Level II codes and descriptors are approved and maintained jointly by the alpha-numeric editorial panel (consisting of CMS, the Health Insurance Association of America, and the Blue Cross and Blue Shield Association). — Updated 6/23/2026

CPT® is a registered trademark of the American Medical Association (AMA). All rights reserved.