Clinical UM Guideline
|Subject:||Lower Limb Prosthesis|
|Guideline #:||CG-DME-13||Current Effective Date:||01/05/2016|
|Status:||Revised||Last Review Date:||11/05/2015|
This document addresses the use of lower limb prostheses required to replace the function of a lower limb loss due to trauma, disease or a congenital condition.
Note: For information addressing microprocessor controlled leg or foot-ankle prosthesis please refer to:
Functional Levels: Throughout this guideline "Functional Levels" are used to guide the appropriateness of lower limb prosthesis. Provided below are definitions of these levels. Please note that within the functional classification hierarchy, bilateral amputees often cannot be strictly bound by functional level classifications.
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance their quality of life or mobility.
Level 1: Has the ability or potential to use 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.
I. Lower Limb: Prosthesis Fitting and Selection
A lower limb prosthesis is considered medically necessary when all the following are met and are documented in the medical record:
Not Medically Necessary:
A lower limb prosthesis is considered not medically necessary when the criteria above have not been met.
A lower limb prosthesis is considered not medically necessary for individuals with a functional level of 0.
Test (diagnostic) sockets for immediate post-surgical or early fitting prostheses are considered not medically necessary.
More than two test (diagnostic) sockets for an individual prosthesis are considered not medically necessary without additional documentation of need.
More than two of the same socket inserts are considered not medically necessary per individual prosthesis at the same time.
II. Lower Limb: Accessories, Maintenance, Repairs and Replacement
Accessories (for example, stump stocking for the residual limb, harness, etc.) are considered medically necessary when these appliances aid in, or are essential to, the effective use of the artificial limb.
Repairs to a prosthesis are considered medically necessary when necessary to make the prosthesis functional.
Maintenance that may be necessitated by manufacturer's recommendations or the construction of the prosthesis and must be performed by the prosthetist is considered medically necessary as a repair.
Adjustments to a prosthesis required by wear and tear or change in an individual's condition are considered medically necessary.
Replacement of a prosthesis or prosthetic component is considered medically necessary if the treating physician orders a replacement device or part because of any of the following:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|L5000-L5020||Partial foot prostheses [includes codes L5000, L5010, L5020]|
|L5050-L5060||Ankle prostheses [includes codes L5050, L5060]|
|L5100-L5105||Below knee prostheses [includes codes L5100, L5105]|
|L5150-L5160||Knee disarticulation (or through knee) prostheses [includes codes L5150, L5160]|
|L5200-L5230||Above knee prostheses [includes codes L5200, L5210, L5220, L5230]|
|L5250-L5270||Hip disarticulation prostheses [includes codes L5250, L5270]|
|L5280||Hemipelvectomy, Canadian type: molded socket, hip joint, single axis 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|
|L5331||Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot|
|L5341||Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot|
|L5400-L5460||Immediate post surgical or early fitting prostheses [includes codes L5400, L5410, L5420, L5430, L5450, L5460]|
|L5500-L5505||Initial prostheses [includes codes L5500, L5505]|
|L5510-L5600||Preparatory prostheses [includes codes L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600]|
|L5610-L5617||Additions to lower extremity prostheses [includes codes L5610, L5611, L5613, L5614, L5616, L5617]|
|L5618-L5629||Additions to lower extremity prostheses, test sockets [includes codes L5618, L5620, L5622, L5624, L5626, L5628, L5629]|
|L5630-L5653||Additions to lower extremity prostheses, socket variations [includes codes L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653]|
|L5654-L5699||Additions to lower extremity prostheses, socket inserts and suspension [includes codes L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699]|
|L5700-L5707||Replacements for lower extremity prostheses [includes codes L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707]|
|L5710-L5795||Additions to lower extremity prostheses, exoskeletal knee-shin system [includes codes L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795]|
|L5810-L5848||Additions to lower extremity prostheses, endoskeletal knee-shin system [includes codes L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848]|
|L5850||Addition, endoskeletal system, above knee or hip disarticulation|
|L5855||Addition, endoskeletal system, hip disarticulation|
|L5910-L5966||Additions to lower extremity prostheses, endoskeletal system [includes codes L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966]|
|L5968-L5990||Additions to lower extremity prostheses [includes codes L5968, L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990]|
|L5999||Addition to lower extremity prosthesis, not otherwise specified|
|L7510-L7520||Repair of prosthetic device [includes codes L7510, L7520]|
|L8400-L8410||Prosthetic sheath [includes codes L8400, L8410]|
|L8417||Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee|
|L8420-L8430||Prosthetic sock, multiple ply [includes codes L8420, L8430]|
|L8440-L8460||Prosthetic shrinker [includes codes L8440, L8460]|
|L8470-L8480||Prosthetic sock, single ply [includes codes L8470, L8480]|
The need for a prosthetic limb is based upon the expectations and judgment of the treating physician or prosthetist regarding the post-treatment expectation of an individual's functional level. Potential function ability is based upon many factors, including but not limited to:
A determination regarding the use or appropriateness of certain components/additions to the prosthesis is also based on the member's potential functional abilities.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||11/05/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Minor clarifications made to Clinical Indications section. Removed ICD-9 codes from Coding section.|
|Reviewed||11/08/2012||MPTAC review. Updated Reference section. Updated coding section with 01/01/2012 HCPCS changes; removed code L7500 deleted 12/31/2011.|
|Reviewed||11/17/2011||MPTAC review. Updated Coding section with 01/01/2012 HCPCS changes; removed code L5311 deleted 12/31/2011.|
|Reviewed||11/18/2010||MPTAC review. Updated Coding section with 01/01/2011 HCPCS changes.|
|New||12/01/2005||MPTAC initial guideline development.|
Last Review Date
|CT DME Coverage Guidelines, Section G: Prostheses: Upper and Lower Limb|
|DME.706||West Region: Lower Limb Prostheses|
|DME-005||Midwest Region: Lower Limb Prosthesis|
|WellPoint Health Networks, Inc.|