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HealthPartners

Coverage criteria policies

Prosthesis-Lower Limb

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for:

  • Prosthetic Limb
  • Microprocessor Controlled Components

Prior authorization is not required for:

  • A partial foot prosthesis
  • Prosthetic repairs, adjustments and/or modifications
  • Prosthetic accessories such as stump/prosthetic sheaths/socks and harnesses when these appliances aid in or are essential to the effective use of the prosthesis

Coverage

A lower limb prosthesis is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. The determination of medical necessity for a prosthesis is based on the member’s potential functional abilities as determined by the prosthetist and ordering physician, considering factors including but not limited to:
    1. Past history, including prior prosthetic use.
    2. Current medical condition including the status of the residual limb and the nature of other medical problems.
    3. Motivation and desire to use the limb.
    4. Ability to obtain or maintain a defined functional state within a reasonable period of time. The Functional Classifications are listed below. A functional level is defined as a measurement of the capacity and potential of the individual to accomplish his/her expected post-rehabilitation daily function. The Centers for Medicare and Medicaid Services (CMS) have defined the following functional levels:

Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance the quality of life or mobility

Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.

Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

  1. The determination of coverage for the selected lower limb prostheses and components with respect to the functional level(s) listed represents the usual case. An exception for medical necessity may be made when there is sufficient clinical documentation to demonstrate that the technologic or design feature of a prosthesis is needed to restore ambulation that will enable an individual to conduct standard activities of daily living.

A basic (i.e. conventional) lower limb prosthesis is eligible for coverage when the member is determined to be a functional Level 1 or greater. A basic limb consists of the following. Associated codes are listed in the coding table below:

  • A socket (connection between the residual limb and prosthesis)
  • A suspension system (how the socket is attached to the prosthesis)
  • A knee joint (provides support, leg control and unrestricted motion for sitting and kneeling). Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage based upon functional classification.
  • A shank or pylon (the internal frame or skeleton that provides structural support)
  • A terminal device (usually includes a foot and ankle). Basic lower extremity prostheses include a solid ankle cushion heel (SACH) foot. Other prosthetic feet are considered for coverage based upon functional classification.

Level 1 options:

  • An external-keel SACH foot (L5970) or single axis ankle/foot (L5974)
  • Knee systems including codes L5611, L5616, L5710-L5718, and L5810-L5818.

Level 2 options:

  • Any of the foot options available at Level 1 or a flexible keel foot (L5972) or multi-axial ankle/foot (L5978).
  • An ankle axial rotation unit (L5982- L5986).
  • Knee systems including codes L5611.L5616, L5710-L5718, and L5810-L5818.

Level 3 options:

  • Any of the foot options available at Level 1 or 2 or one of the following: Energy storing foot (L5976), dynamic response with multi-axial ankle (L5979), flex-foot system (L5980), flex-walk system or equal (L5981), microprocessor-controlled ankle/foot (L5973), or shank system with vertical loading pylon (L5987).
  • An ankle axial rotation unit (L5982- L5986)
  • Any knee system available at Levels 1 or 2 or one of the following: A fluid, pneumatic or electronic knee (L5610, L5613, L5614, L5722-L5780, L5822-L5840, L5848, L5856, L5857, L5858).

Level 4 options:

  • Any of the options available above for foot, ankle, knee with the additional option of a high activity knee control frame (L5930)
  1. A microprocessor controlled knee prosthesis and associated components may be eligible for coverage when all of the following criteria are met:
    1. The member has sustained a transfemoral or knee disarticulation amputation.
    2. The member’s functional level is a 3 or 4 as defined above.
    3. The member has the cognitive ability to master the gait sequencing and care requirements of the higher level of technology.
    4. The member demonstrates the ability to ambulate at a faster than baseline rate using a standard prosthetic with a swing and stance control knee.
    5. The member has adequate cardiovascular, neuromuscular, and pulmonary reserve needed for ambulating at a faster than baseline rate.
    6. The member demonstrates a need for long distance ambulation (greater than 400 yards) at variable rates on a daily basis. Basic community ambulation is not sufficient to justify a microprocessor controlled knee prosthetic over a standard prosthetic limb.
    7. The member demonstrates a need for regular ambulation on uneven terrain or for regular use on stairs. (Limited stair climbing in the home or in the employment environment is not sufficient).
  2. A prosthetic shoe (L3250) is considered medically necessary for a member with a partial foot amputation when the prosthetic shoe is an integral part of a covered basic lower limb prosthetic device. These types of devices are used when all or most of the forefoot is missing and are considered terminal devices. Prosthetic shoes for other conditions are considered not medically necessary.
  3. Sockets: No more than two test (diagnostic) sockets for an individual prosthesis are considered medically necessary without additional documentation. No more than two of the same socket inserts are allowed at the same time. Socket replacements are considered medically necessary if there is documentation of functional and/or physiological need. Documentation must include but is not limited to:
    1. Residual limb changes
    2. Functional need changes
    3. Irreparable damage
    4. Wear and tear due to excessive weight
    5. Prosthetic demands of a very active amputee
  4. Lower Limb Prosthetic covers: Custom shaped protective covers (L5704, L5705, L5706, L5707) are considered medically necessary as the offer shape, protection and waterproofing for normal daily usage of a lower limb prosthesis.
  5. Accessories: Accessories such as stump socks, harnesses and batteries are covered only when they aid in or are essential to the effective use of the prosthesis.
  6. Adjustments: Adjustments and/or modifications to the prosthesis required by wear and tear or due to a change in individual's condition or to improve the function are eligible for coverage and do not require prior authorization.
  7. Repairs: Repairs necessary to make the prosthetic functional are covered and do not require authorization. The expense for repairs may not exceed the estimated expense of purchasing another prosthesis.
  8. Replacement: The usual life of a prosthesis is approximately 5 years. A replacement prosthesis is covered only if the previous prosthesis is no longer functional. Requests for prosthetic limb upgrades/newer technology will be reviewed for medical necessity.

Indications that are not covered

  1. Powered microprocessor components (L5859 and L5969) are considered investigational. (Please see Related Content section for specific information on coverage of these items for Minnesota Health Care Program members).
  2. Protective outer surface covering systems (L5962, L5964, L5966) are not considered medically necessary as they are intended for protection against unusually harsh environmental conditions that are not typical of use for ADL’s.
  3. A prosthetic donning sleeve (L7600) is not considered medically necessary
  4. User adjustable heel height feature for a prosthetic foot (L5990) is not considered medically necessary
  5. A prosthesis is not considered medically necessary when the functional level is 0.
  6. A prosthesis is considered cosmetic and is not covered when request for appearance alone. Medical Necessity requires that the prosthesis enables the member to conduct standard activities of daily living.
  7. Duplicate or similar items are excluded from coverage. Therefore, only one permanent prosthesis is covered unless a member requires bilateral prostheses
  8. Repairs, components, or prosthesis replacement are not covered if the plan determines that malicious damage, culpable neglect or wrongful disposition of the prosthesis has occurred

Definitions

Activities of daily living (ADLs) - refers to a set of common, everyday tasks (as defined by the U.S. Department of Health and Human Services), performance of which are required for personal self-care and independent living; bathing, dressing, eating, toileting and transferring the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring.

Investigational- A service or item is defined as investigational when there is insufficient reliable evidence in the form of high quality peer-reviewed medical literature to establish the safety and efficacy of the treatment or its effect on health care outcomes.

Medicare Functional Classification Level – system used by Medicare’s Durable Medical Equipment Contractor (DMERC) to establish the medical necessity of lower limb prosthetics. Levels are based on an individual’s ability or potential to ambulate and navigate their environment.

Microprocessor controlled prosthesis – one of the three types of prosthetic legs available to restore the capacity to walk. In a microprocessor controlled prosthetic knee, a battery powered (microprocessor controlled) hydraulic knee constantly analyzes and interprets data from strain and rotation sensors. Examples microprocessor controlled knee prosthetics include the C-Leg, the C-Leg compact, and Genium (Otto Bock HealthCare LP); SmartIP (Endolite North America); and the Ossur Rheo Knee (Ossur).

Prosthetic - the systematic pursuit of providing functional restoration of a limb.

Prosthesis - an artificial part of the body. In cases of an amputee, usually an arm or leg. There usually are a couple stages to prepare the limb for a permanent prosthesis.

Prosthesis/Permanent - the final prosthesis once the limb has stabilized shape and size.

Prosthesis/Preparatory - a prosthesis that prepares the limb for a permanent prosthesis. A preparatory prosthesis is used by individuals who are still undergoing changes to the residual limb. This prosthesis uses a transparent diagnostic test socket and special fitting techniques to accurately fit the prosthesis. As a result, fitting problems can be prevented before the prosthesis is cloned for the permanent prosthesis.

Prosthesis/Temporary - a prosthesis usually made soon after an amputation and once the stitches are removed (about 2-6 weeks post amputation). The temporary prosthesis shrinks, toughens and desensitizes the limb to prepare it for the permanent prosthesis. A lower limb temporarily helps to regain balance, relearn walking and tightening of the muscles. An upper limb temporarily helps to increase range of motion, strengthen muscles and encourage the use of both hands, preventing an individual from becoming one handed.

Prosthetist - as defined by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. is a healthcare professional who measures, designs, fabricates, fits, or services a prosthesis as prescribed by a licensed physician, and who assists in the formulation of the prosthesis prescription for the replacement of external parts of the human body lost due to amputation or congenital deformities or absences

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes associated with a basic lower limb prosthetic device.

    Codes

    Description

    L5050

    Ankle, symes, molded socket, sach foot

    L5060

    Ankle, symes, metal frame, molded leather socket, articulated ankle/foot

    L5100

    Below knee, molded socket, shin, sach foot

    L5105

    Below knee, plastic socket, joints and thigh lacer, sach foot

    L5150

    Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot

    L5160

    Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot

    L5200

    Above knee, molded socket, single axis constant friction knee, shin, sach foot

    L5210

    Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no ankle joints, each

    L5220

    Above knee, short prosthesis, no knee joint ('stubbies'), with articulated ankle/foot, dynamically aligned, each

    L5230

    Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot

    L5301

    Below knee, molded socket, shin, each foot, endoskeletal system

    L5312

    Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system

    L5321

    Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee

    L5970

    All lower extremity prosthesis; foot, external keel, each foot

    L5971

    All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

    L5972

    All lower extremity prosthesis, flexible keel foot (Safe, Sten, Bock Dynamic or equal)

    L5974

    All lower extremity prosthesis, foot, single axis ankle/foot

    L5975

    All lower extremity prosthesis; combination single axis ankle and flexible keel foot

    L5976

    All lower extremity prosthesis; energy storing foot (Seattle Carbon Copy II or equal)

    L5978

    All lower extremity prosthesis; foot, multiaxial ankle/foot

    L5979

    All lower extremity prosthesis; multiaxial ankle, dynamic response foot, one piece system

    L5980

    All lower extremity prosthesis; flexfoot system

    L5981

    All lower extremity prosthesis; flex-walk system or equal

    L5982

    All exoskeletal lower extremity prosthesis, axial rotation unit

    L5984

    All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability

    L5985

    All endoskeletal lower extremity prosthesis, dynamic prosthetic pylon

    L5986

    All lower extremity prostheses, multi-axial rotation unit ("MCP" or equal)

    L5987

    All lower extremity prosthesis, shank foot system with vertical loading pylon

    L5999

    Lower extremity prosthesis, not otherwise specified (used to report a medically necessary lower limb prosthetic device in the absence of a specific code. Documentation of medical necessity is required)

Codes for basic additions to a lower limb prosthetic device.

Codes

Description

    L5610

    Addition to lower extremity, endoskeletal system, above knee, hydracadence system

    L5611

    Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control

    L5613

    Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control

    L5614

    Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control

    L5616

    Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control

    L5617

    Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each

    L5618

    Addition to lower extremity, test socket, symes

    L5620

    Addition to lower extremity, test socket, below knee

    L5622

    Addition to lower extremity, test socket, knee disarticulation

    L5624

    Addition to lower extremity, test socket, above knee

    L5629

    Addition to lower extremity, below knee, acrylic socket

    L5630

    Addition to lower extremity, symes type, expandable wall socket

    L5631

    Addition to lower extremity, above knee or knee disarticulation, acrylic socket

    L5632

    Addition to lower extremity, symes type, 'ptb' brim design socket

    L5634

    Addition to lower extremity, symes type, posterior opening (canadian) socket

    L5636

    Addition to lower extremity, symes type, medial opening socket

    L5637

    Addition to lower extremity, below knee, total contact

    L5638

    Addition to lower extremity, below knee, leather socket

    L5639

    Addition to lower extremity, below knee, wood socket

    L5640

    Addition to lower extremity, knee disarticulation, leather socket

    L5642

    Addition to lower extremity, above knee, leather socket

    L5643

    Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

    L5644

    Addition to lower extremity, above knee, wood socket

    L5645

    Addition to lower extremity, below knee, flexible inner socket, external frame

    L5646

    Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket

    L5647

    Addition to lower extremity, below knee suction socket

    L5648

    Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket

    L5650

    Additions to lower extremity, total contact, above knee or knee disarticulation socket

    L5651

    Addition to lower extremity, above knee, flexible inner socket, external frame

    L5652

    Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

    L5653

    Addition to lower extremity, knee disarticulation, expandable wall socket

    L5654

    Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal)

    L5655

    Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal)

    L5656

    Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal)

    L5658

    Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal)

    L5661

    Addition to lower extremity, socket insert, multi-durometer symes

    L5565

    Addition to lower extremity, socket insert, multi-durometer, below knee

    L5666

    Addition to lower extremity, below knee, cuff suspension

    L5668

    Addition to lower extremity, below knee, molded distal cushion

    L5670

    Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar

    L5671

    Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert

    L5672

    Addition to lower extremity, below knee, removable medial brim suspension

    L5673

    Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

    L5676

    Additions to lower extremity, below knee, knee joints, single axis, pair

    L5677

    Additions to lower extremity, below knee, knee joints, polycentric, pair

    L5678

    Additions to lower extremity, below knee, joint covers, pair

    L5679

    Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

    L5680

    Addition to lower extremity, below knee, thigh lacer, nonmolded

    L5681

    Addition to lower extremity; below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

    L5682

    Addition to lower extremity; below knee, thigh lacer, gluteal/ischial, molded

    L5683

    Addition to lower extremity; below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

    L5684

    Addition to lower extremity; below knee, fork strap

    L5685

    Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each

    L5686

    Addition to lower extremity, below knee, back check (extension control)

    L5688

    Addition to lower extremity, below knee, waist belt, webbing

    L5690

    Addition to lower extremity, below knee, waist belt, padded and lined

    L5692

    Addition to lower extremity, above knee; pelvic control belt, light

    L5694

    Addition to lower extremity, above knee; pelvic control belt, padded and lined

    L5695

    Addition to lower extremity, above knee; pelvic control, sleeve suspension, neoprene or equal, each

    L5696

    Addition to lower extremity, above knee or knee disarticulation; pelvic joint

    L5697

    Addition to lower extremity, above knee or knee disarticulation; pelvic band

    L5698

    Addition to lower extremity, above knee or knee disarticulation; silesian bandage

    L5699

    All lower extremity prostheses, shoulder harness

    L5700

    Replacement, socket; below knee, molded to patient model

    L5701

    Replacement, socket; above knee/knee disarticulation, including attachment plate, molded to patient model

    L5703

    Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (Sach) foot, replacement only

    L5704

    Custom shaped protective cover, below knee

    L5705

    Custom shaped protective cover, above knee

    L5706

    Custom shaped protective cover, knee disarticulation

    L5710

    Addition, exoskeletal knee-shin system, single axis; manual lock

    L5711

    Addition, exoskeletal knee-shin system, single axis; manual lock, ultra-light material

    L5712

    Addition, exoskeletal knee-shin system, single axis; friction swing and stance phase control (safety knee)

    L5714

    Addition, exoskeletal knee-shin system, single axis; variable friction swing phase control

    L5716

    Addition, exoskeletal knee-shin system, polycentric; mechanical stance phase lock

    L5718

    Addition, exoskeletal knee-shin system, polycentric; friction swing and stance phase control

    L5722

    Addition, exoskeletal knee-shin system, single axis; pneumatic swing, friction stance phase control

    L5724

    Addition, exoskeletal knee-shin system, single axis; fluid swing phase control

    L5726

    Addition, exoskeletal knee-shin system, single axis; external joints, fluid swing

    L5728

    Addition, exoskeletal knee-shin system, single axis; fluid swing and stance phase contro

    L5780

    Addition, exoskeletal knee-shin system, single axis; pneumatic/hydrapneumatic swing phase control

    L5781

    Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

    L5782

    Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty

    L5785

    Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

    L5790

    Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

    L5810

    Addition, endoskeletal knee-shin system, single axis; manual lock

    L5811

    Addition, endoskeletal knee-shin system, single axis; manual lock, ultra-light

    material

    L5812

    Addition, endoskeletal knee-shin system, single axis; friction swing and stance

    phase control (safety knee)

    L5814

    Addition, endoskeletal knee-shin system, polycentric; hydraulic swing phase

    control, mechanical stance phase lock

    L5816

    Addition, endoskeletal knee-shin system, polycentric; mechanical stance phase

    lock

    L5818

    Addition, endoskeletal knee-shin system, polycentric; friction swing and stance

    phase control

    L5822

    Addition, endoskeletal knee-shin system, single axis; pneumatic swing, friction

    stance phase control

    L5824

    Addition, endoskeletal knee-shin system, single axis; fluid swing phase control

    L5826

    Addition, endoskeletal knee-shin system, single axis; hydraulic swing phase

    control, with miniature high activity frame

    L5828

    Addition, endoskeletal knee-shin system, single axis; fluid swing and stance

    phase control

    L5830

    Addition, endoskeletal knee-shin system, single axis; pneumatic swing phase

    control

    L5840

    Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic

    swing phase control

    L5845

    Addition, endoskeletal knee-shin system ; stance flexion feature, adjustable

    L5848

    Addition to endoskeletal knee shin system, fluid stance extension, dampening

    feature, with or without adjustability

    L5850

    Addition, endoskeletal system; above knee or hip disarticulation, knee extension

    assist

    L5910

    Addition, endoskeletal system; below knee, alignable system

    L5920

    Addition, endoskeletal system; above knee or hip disarticulation, alignable

    system

    L5925

    Addition, endoskeletal system; above knee, knee disarticulation or hip

    disarticulation, manual lock

    L5930

    Addition, endoskeletal system; high activity knee control frame

    L5940

    Addition, endoskeletal system; below knee, ultra-light material (titanium, carbon

    fiber or equal)

    L5950

    Addition, endoskeletal system; above knee, ultra-light material (titanium, carbon

    fiber or equal)

    L5968

    Addition to lower limb prosthesis, multiaxial ankle with swing phase active

    dorsiflexion feature

    L5988

    Addition to lower limb prosthesis, vertical shock reducing pylon feature

    L5999

    Lower extremity prosthesis, not otherwise specified

Codes for microprocessor-controlled prosthesis (base codes)

Codes

Description

    L5856

    Addition to lower extremity prosthesis, endoskeletal knee-shin system,

    microprocessor control feature, swing and stance phase, includes electronic

    sensor(s), any type

    L5857

    Addition to lower extremity prosthesis, endoskeletal knee-shin system,

    microprocessor control feature, swing phase only, includes electronic sensor(s),

    any type

    L5858

    Addition to lower extremity prosthesis, endoskeletal knee shin system,

    microprocessor control feature, stance phase only, includes electronic sensor(s),

    any type

    L5973

    Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion

    and/or plantar flexion control, includes power source

Codes for microprocessor-controlled prosthesis (additional components/features)

Codes

Description

    L5828

    Addition, endoskeletal knee-shin system, single axis; fluid swing and stance

    phase contro

    L5845

    Addition, endoskeletal knee-shin system; stance flexion feature, adjustable

    L5848

    Addition to endoskeletal, knee-shin system, fluid stance extension, dampening

    feature, with or without adjustability

    L5920

    Addition, endoskeletal system; above knee or hip disarticulation, alignable system

    L5925

    Addition, endoskeletal system; above knee, knee disarticulation or hip

    disarticulation, manual lock

    L5930

    Addition, endoskeletal system; high activity knee control frame

    L5950

    Addition, endoskeletal system; above knee, ultra-light material (titanium, carbon

    fiber or equal)

    L5999

    Lower extremity prosthesis, not otherwise specified

Codes for prosthetic shoe

Codes

Description

    L3250

    Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic

    shoe, each

Codes for which prior authorization is not required

Codes

Description

    L5000

    Partial foot; shoe insert with longitudinal arch, toe filler

    L5010

    Partial foot; molded socket, ankle height, with toe filler

    L5020

    Partial foot; molded socket, tibial tubercle height, with toe filler

    L7510

    Repair of prosthetic device, repair or replace minor parts

    L7520

    Repair prosthetic device, labor component, per 15 minutes

    L8400

    Prosthetic sheath, below knee, each

    L8410

    Prosthetic sheath, above knee, each

    L8417

    Prosthetic sheath/sock, including gel cushion layer, below or above knee, each

    L8420

    Prosthetic sheath/sock, multiple ply, below knee, each

    L8430

    Prosthetic sheath/sock, multiple ply, above knee, each

    L8440

    Prosthetic shrinker, below knee, each

    L8460

    Prosthetic shrinker, above knee, each

    L8470

    Prosthetic sock, single ply, fitting, below knee, each

    L8480

    Prosthetic sock, single ply, fitting, above knee, each

Codes which are considered investigational and are not covered

Codes

Description

L5859

Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

L5969

Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)

Codes which are considered not medically necessary and are not covered

Codes

Description

L5962

Addition, endoskeletal system, below knee, flexible protective outer surface covering system

L5964

Addition, endoskeletal system, above knee, flexible protective outer surface covering system

L5966

Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

L5990

Addition to lower extremity prosthesis, user adjustable heel height

L7600

Prosthetic donning sleeve, any material, each

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Aldridge, J., Sturdy, J. and Wilken, J. (2012). Stair ascent kinematics and kinetics with a powered lower leg system following transtibial amputation. Gait and Posture. 36(2): 291-295.
  2. Bellmann, M, Schmalz, T., Ludwigs, E. Blumentritt, S. (2012). Immediate Effects of a New Microprocessor-Controlled Prosthetic Knee Joint: A Comparative Biomechanical Evaluation. Archives of Physical Medicine and Rehabilitation. 93:54 (1-9).
  3. California Technology Assessment Forum (2007) Microprocessor-Controlled Prosthetic Knees-A Technology Assessment. Retrieved from https://icer-review.org on April 4, 2017.
  4. ECRI Institute. (2012). Hotline Response: Microprocessor-controlled Lower-Extremity Prostheses for Enhancing Amputee Ambulation. Plymouth Meeting, PA: ECRI Institute.
  5. ECRI Institute. (2008). Hotline Response: Microprocessor-controlled Ankle-Foot Prostheses for Improving Ambulation in Lower-limb Amputees. Plymouth Meeting, PA: ECRI Institute.
  6. Esposito, R. Whitehead, A. and Wilken, J. (2016). Step-to-step transition work during level and inclined walking using passive and powered ankle-foot prostheses. Prosthetics and Orthotics International. 40(3):311-319.
  7. Fairley, M. (2014) Microprocessor-Controlled Knees: Evolution of a Game Changer. The O & P Edge. Retrieved from http://www.oandp.com/articles on 5/4/2017.
  8. Fitzgerald, R. (2013) A Guide To Orthotic And Prosthetic Options For People With Partial Foot Amputations. Podiatry Today, 26:9(1-2).
  9. Grabowski, A. and D’Andrea, S. (2013) Effects of a powered ankle-foot prosthesis on kinetic loading of the unaffected leg during level-ground walking. Journal of NeuroEngineering and Rehabilitation, 10(49):1-11.
  10. Hafner, B. , Willingham, L. , Buell, N. , Allyn, K. and Smith, D. (2007) Evaluation of Function, Performance, and Preference as Trasnfemoral Amputees Transition from Mechanical to Microprocessor-Control of the Prosthetic Knee. Archive of Physical Medicine and Rehabilitation. 88(2): 207-217.
  11. Hayes, Inc. Hayes Health Technology Brief. C-leg Prostheses (Ottto Bock HealthCare LP) for Patients with Above-Knee Amputation. Lansdale, PA: Hayes, Inc.: Jan, 2013. Reviewed Jan, 2015.
  12. Henrikson, N., Hafner, B., Dettori, J.,Norvell, D., Raich, A., Brodt, E. and Skelly, A. (2011) Microprocessor Controlled Lower Limb Prostheses- Health Technology Assessment. Washington State Health Care Authority. Retrieved from http://www.hta.hca.wa.gov
  13. Herr, H. and Grabowski, A. (2012). Bionic ankle-foot prosthesis normalizes walking gait for person with leg amputation. Proceedings-Biological Sciences. 279(1728): 457-464.
  14. Highsmith, M., Kahle, J., Bongiorni, D. Sutton, B., Groer, S. and Kaufman, K. (2010). Safety, Energy Efficiency, and Cost Efficacy of the C-leg for Transfemoral Amputees: A review of the Literature. Prosthetics and Orthotics International. 34(4): 362-377.
  15. Kalapatapu, V. Techniques for lower extremity amputation. In: UpToDate, Mills, J and Eidt, J. (Ed), UpToDate, Waltham, MA. (Accessed on 5/4/2017).
  16. Kaufman, K. Frittoli, S. and Frigo, C. (2012) Gait asymmetry of transfemoral amputees using mechanical and microprocessot-controlled prosthetic knees. Clinical Biomechanics. 27(5): 460-465.
  17. Kaufman, K., Levine, J. , Brey, B. , Iverson, B. McCrady, D. , Padgett, D. and Joyner, M. (2007) Gait and balance of transfemoral amputees using passive mechanical and microprocessor-controlled prosthetic knees. Gait & Posture. 26(4): 489-493.
  18. Kaufman, K., Levine, J. , Brey, R. , McCrady, S. Padgett, D. and Joyner, M. (2008) Energy Expenditure and Activity of Transfemoral Amputees Using Mechanical and Microprocessor-Controlled Prosthetic Knees. Archives of Physical Medicine and Rehabilitation. 89(7):1380-1385.
  19. Kistenberg, R. (2014) Prosthetic Choices for People with Leg and Arm Amputatons. Physical Medicine and Rehabilitation Clinics of North America, 25:1(93-115).
  20. Laferrier, J. and Gailey, R. (2010) Advances in Lower-limb Prosthetic Technology. Physical Medicine and Rehabilitation Clinics of North America. 21(1):87-110.
  21. Rossbach, P. Amputee Coalition of America (2008). When to replace a prosthesis. Fact Sheet. National Limb Loss Information Center. Retrieved on 8/5/2017 from http://www.amputee-coalition.org
  22. Simon, A., Fey, N., Ingraham, K., Finucane, S., Halsne, E. and Hargrove, L. (2016). Improved Weight-Bearing Symmetry for Transfemoral Amputees During Standing Up and Sitting Down With a Powered Knee-Ankle Prosthesis. Archives of Physical Medicine and Rehabilitation. 97(7): 1100-1106.
  23. Struchkov, V. and Buckley, J. (2015) Biomechanics of ramp descent in unilateral trans-tibial amputees: Comparison of a microprocessor controlled foot with conventional ankle-foot mechanisms. Clinical Biomechanics, 32(2016):164-170.
  24. United States Department of Veterans Affairs. (2000). Computerized Lower Limb Prostheses. Veterans Health Administration, Office of Research and Development. Technology Assessment Program.Retrieved from http://www4.va.gov/vatap/publications.asp

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Policy activity

  • 01/01/1998 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 04/2017
Revision date
  • 06/29/2017

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