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Lower Limb Prostheses

Policy Number: MP-094

 Latest Review Date: July 2021

Category: Durable Medical Equipment                                

Policy Grade:  D

POLICY:

For dates or service on or after May 1, 2020:

Lower limb prosthesis may be considered medically necessary when the following criteria are met:

  • The patient will reach or maintain a defined functional state within a reasonable period of time;
  • The patient is motivated to ambulate; and
  • The prosthesis is furnished incident to a physician’s services or on a physician’s order. 

Determination of medical criteria for coverage for prostheses is also based on the patient’s potential functional level (see Description of Procedure or Service).

Replacement or repair of prosthetic parts or prosthesis may be considered medically necessary when there is adequate documentation of functional and/or physiological need such as, but not limited to; changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of very active amputees.

PROSTHETIC FEET

Medical criteria for coverage for selected foot prostheses and components is determined according to potential functional levels (see Description of Procedure or Service).  Determination of the type of prosthetic foot will be made by the prescribing physician and/or prosthetist based on the functional needs of the patient. 

External keel (L5972), SACH foot (L5970) or single axis ankle/foot (L5974) may be considered medically necessary for patients with functional Level 1 or above.

Flexible-keel foot (L5972) and multiaxial ankle/foot (L5978) may be considered medically necessary for patients with functional Level 2 or greater.

Flex foot system (L5980), energy storing foot (L5976), multiaxial, dynamic response ankle/foot (L5979), or flex walk system or equal (L5981) or shank foot system with vertical loading pylon (L5987) may be considered medically necessary for patients with functional Level 3 or above.

PROSTHETIC KNEE

Medical criteria for coverage for selected knee prostheses and components is determined according to potential functional levels.  Determination of the type of prosthetic knee will be made by the prescribing physician and/or prosthetist based on the functional needs of the patient. 

Knee systems L5611, L5616, L5710-L5718, and L5810-L5818 may be considered medically necessary for patients with functional Level 1 or above. 

Fluid and pneumatic knees (L5610, L5613, L5614, L5722-L5780, L5822-L5840) may be considered medically necessary for patients with functional Level 3 or above.

See Medical Policy #083 for coverage of Microprocessor/ Computerized Knee Prostheses.

PROSTHETIC ANKLE

Axial rotation units (L5982-L5986) may be considered medically necessary for patients with functional Level 2 or above.

PROSTHETIC HIP

A pneumatic or hydraulic polycentric hip joint (L5961) is considered medically necessary for members whose functional level is 3 or above.

SOCKETS

Test (diagnostic) sockets for immediate post-surgical or early fitted prostheses (L5618-L5628 when used with L5400-L5460) are considered not medically necessary. Immediate prostheses are considered not medically necessary. 

Test sockets for permanent prostheses may be considered medically necessary.

No more than two of the same socket inserts (L5654-L5665,L5673, L5679, L5681, L5683) per individual prosthesis are considered medically necessary at the same time.

Socket replacements may be considered medically necessary when there is adequate documentation of functional and/or physiological need such as, but not limited to; changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of very active amputees.

Lifelike components (i.e., silicone covered prosthesis) are considered not medically necessary and cosmetic. Consideration will be given for reimbursement of a basic component if the basic component meets medical criteria for coverage.

Specialized vacuum pump residual limb volume management and moisture evacuation systems (L5781,L5782), may be considered medically necessary for use with lower limb prostheses when there is contraindication to or failure of other socket-suspension systems (e.g., mechanical, passive suction) to adequately secure the limb to the prosthesis AND any of the following criteria are met:

  • Excessive pistoning of the socket to residual limb interface that cannot be resolved by adjustments in the current suspension system; or
  • Excessive residual limb hyperemia from prior socket use; or
  • Excessive skin hyperhidrosis from prior socket use; or
  • Multiple documented falls.

For dates of service prior to May 1, 2020:

Lower limb prosthesis may be considered medically necessary when the following criteria are met:

  • The patient will reach or maintain a defined functional state within a reasonable period of time;
  • The patient is motivated to ambulate; and
  • The prosthesis is furnished incident to a physician’s services or on a physician’s order. 

Determination of medical criteria for coverage for prostheses is also based on the patient’s potential functional level (see Description of Procedure or Service).

Replacement or repair of prosthetic parts or prosthesis may be considered medically necessary when there is adequate documentation of functional and/or physiological need such as, but not limited to; changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of very active amputees.

PROSTHETIC FEET

Medical criteria for coverage for selected foot prostheses and components is determined according to potential functional levels (see Description of Procedure or Service).  Determination of the type of prosthetic foot will be made by the prescribing physician and/or prosthetist based on the functional needs of the patient. 

External keel (L5972), SACH foot (L5970) or single axis ankle/foot (L5974) may be considered medically necessary for patients with functional Level 1 or above.

Flexible-keel foot (L5972) and multiaxial ankle/foot (L5978) may be considered medically necessary for patients with functional Level 2 or greater.

Flex foot system (L5980), energy storing foot (L5976), multiaxial, dynamic response ankle/foot (L5979), or flex walk system or equal (L5981) or shank foot system with vertical loading pylon (L5987) may be considered medically necessary for patients with functional Level 3 or above.

PROSTHETIC KNEE

Medical criteria for coverage for selected knee prostheses and components is determined according to potential functional levels.  Determination of the type of prosthetic knee will be made by the prescribing physician and/or prosthetist based on the functional needs of the patient. 

Knee systems L5611, L5616, L5710-L5718, and L5810-L5818 may be considered medically necessary for patients with functional Level 1 or above. 

Fluid and pneumatic knees (L5610, L5613, L5614, L5722-L5780, L5822-L5840) may be considered medically necessary for patients with functional Level 3 or above.

See Medical Policy #083 for coverage of Microprocessor/ Computerized Knee Prostheses.

PROSTHETIC ANKLE

Axial rotation units (L5982-L5986) may be considered medically necessary for patients with functional Level 2 or above.

PROSTHETIC HIP

A pneumatic or hydraulic polycentric hip joint (L5961) is considered medically necessary for members whose functional level is 3 or above.

SOCKETS

Test (diagnostic) sockets for immediate post-surgical or early fitted prostheses (L5618-L5628 when used with L5400-L5460) are considered not medically necessary. Immediate prostheses are considered not medically necessary. 

Test sockets for permanent prostheses may be considered medically necessary.

No more than two of the same socket inserts (L5654-L5665) per individual prosthesis are considered medically necessary at the same time.

Socket replacements may be considered medically necessary when there is adequate documentation of functional and/or physiological need such as, but not limited to; changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive patient weight or prosthetic demands of very active amputees.

Lifelike components (i.e., silicone covered prosthesis) are considered not medically necessary and cosmetic. Consideration will be given for reimbursement of a basic component if the basic component meets medical criteria for coverage.

Vacuum Assisted Socket Systems (e.g. VASS™; Otto Bock Harmony® P4 System) (L5781, L5782) are considered not medically necessary and investigational due to a lack of evidence in the published peer-reviewed literature.

DESCRIPTION OF PROCEDURE OF SERVICE:

A prosthesis or prosthetic is an artificial device that replaces a missing body part. Examples of prostheses include eyes, maxillofacial (jaw and face), arms, breasts, ears, legs, hands and feet.

Lower Limb Prosthesis

A lower limb prosthesis is designed to replace portions of the lower extremity to improve function. A prosthetic knee performs several functions: it provides support during the stance phase of ambulation, produces smooth control during the swing phase and maintains unrestricted motion for sitting and kneeling. The prosthetic knee may have a single axis with a simple hinge and a single pivot point or it may have a polycentric axis with multiple centers of rotation, which is more similar to the anatomic human knee. Pylons are the connection between the residual limb and the prosthetic joint.

A basic (i.e., conventional) lower limb prosthetic device consists of the following:

  • a socket (connection between the residual limb and prosthesis)
  • a suspension mechanism (how the socket is attached to the prosthesis)
  • a knee joint (provides support during stance, smooth control during swing phase and unrestricted motion for sitting and kneeling)
  • a pylon (a tube or shell that attaches the socket to the terminal device) that is either exoskeleton or endoskeleton
  • a terminal device (foot)

Knee Prosthetics

The basic lower-extremity prosthesis includes a single-axis, constant friction knee. This device is a basic knee that acts as a door-and-hinge device, is free-swinging and does not allow stance control. It allows one-speed ambulation and is often used in children. A hydraulic unit that includes piston cylinders and contains either air (i.e., pneumatic) or fluid (i.e., hydraulic) may be added to the knee device to allow swing control as the amputee speeds up or slows down. Swing control may allow the amputee to walk at variable speeds. It is often used in more active amputees. The polycentric knee, a device with multiple rotational axes, is sometimes referred to as the “four bar” knee. It has four points of rotation connected by a linkage bar. The device is asserted to be very stable in early stance and easy to flex in swing phase.

Prosthetic Feet

The prosthetic foot also has several basic functions: provides a stable weight-bearing surface, absorbs shock, replaces lost muscle function and biomechanics of the foot, replicates the anatomic joints of the ankle and foot and restores appearance.

Multiaxial prosthetic feet permit movements in any direction: plantar flexion, dorsiflexion, inversion, eversion and a slight amount of rotation around a vertical axis. Multiaxial feet are appropriate for those who ambulate on uneven terrain, such as community ambulators and active adults or athletes.

The solid ankle cushion heel (SACH) consists of a rigid keel covered by semi-noncompressible foam and a synthetic rubber heel wedge. The cushion heel compresses when weight is applied, allowing the forefoot to approach the floor. The amount of simulated plantar flexion depends on the relative softness of the heel material and weight of the amputee. Because the keel is rigid, the SACH foot does not provide dorsiflexion; this makes its usefulness on uneven surfaces limited.

Potential functional ability is based on the reasonable expectations of the prosthetist and treating physician, considering factors including, but not limited to:

  1. the patient’s past history (including prior prosthetic use if applicable);
  2. the patient’s current condition including the status of the residual limb and the nature of other medical problems; and
  3. the patient’s desire to ambulate. 

Clinical assessments of the patient’s rehabilitation potential should be based on the following classification levels.   Medical records should document the patient’s current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case.

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 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 active adult.

KEY POINTS:

The most recent literature search for this policy was performed through July 2021. 

SUMMARY OF EVIDENCE:

Appropriate selection of componentry for prosthetic restoration of the amputee is an extremely important and challenging task in view of the variety and complexity of available prosthetic devices and the functional requirements of patients. After prescription and fitting of the device, training is indispensable and should include prosthetic management and functional training with the goal of achieving community reintegration.

KEY WORDS:

Prosthetic leg, prosthetic knee, prosthetic ankle, prosthetic foot, leg prosthesis, foot prosthesis, ankle prosthesis, knee prosthesis, artificial leg, artificial knee, artificial ankle, artificial foot, vacuum assisted socket system, VASS, hip prosthetic,socket insert, Harmony® P4 vacuum pump, SACH foot

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:    

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

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, bent knee configuration, external knee

L5160

Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee

 

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

 

L5250

Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

L5270

Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot

L5280

Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

 

L5301

Below knee, molded socket, shin, SACH 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

Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment

L5410

Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment

L5420

Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change “AK” or knee disarticulation

L5430

Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, “AK” or knee disarticulation, each additional cast change and realignment

L5450

Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee

L5460

Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee

L5500

Initial, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed

L5505

Initial, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formed

L5510

Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5520

Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5530

Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model.

 

L5535

Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket

L5540

Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model

L5560

Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5570

Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

L5580

Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5585

Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open-end socket

L5590

Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model

 

L5595

Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model

L5600

Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model

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 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

L5626

Addition to lower extremity, test socket, hip disarticulation

L5628

Addition to lower extremity, test socket, hemipelvectomy

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, l84

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 cushion socket

L5647

Addition to lower extremity, below knee, suction socket

L5648

Addition to lower extremity, above knee, air cushion socket

L5649

Addition to lower extremity, ischial containment/narrow M-L socket

L5650

Addition 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

L5665

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, non-molded

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

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

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 joint

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

L5702

Replacement, socket, hip disarticulation, including hip joint, molded to patient model

L5703

Ankle, Symes, molded to patient model, socket without solid ankle cushion heel

L5704

Custom shaped protective cover, below knee

L5705

Custom shaped protective cover, above knee

L5706

Custom shaped protective cover, knee disarticulation

L5707

Custom shaped protective cover, hip 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 phase control

L5728

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

L5780

Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic 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)

L5795

Addition, exoskeletal system, hip disarticulation, 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 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

L5855

Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

L5858

Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

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)

L5960

Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

L5961

Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control

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

L5968

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

L5970

All lower extremity prostheses, foot, external keel, SACH foot

L5971

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

L5972

All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock dynamic or equal)

L5974

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

L5975

All lower extremity prostheses, combination single axis ankle and flexible keel foot

L5976

All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

L5978

All lower extremity prostheses, foot, multiaxial ankle/foot

L5979

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

L5980

All lower extremity prostheses, flex foot system

L5981

All lower extremity prostheses, flex-walk system or equal

L5982

All exoskeletal lower extremity prostheses, axial rotation unit

L5984

All endoskeletal lower extremity prostheses, axial rotation unit

L5985

All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

L5986

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

L5987

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

L5988

Addition to lower limb prosthesis, vertical shock reducing pylon feature

L5990

Addition to lower extremity prosthesis, user adjustable heel height

L5999

Lower extremity prosthesis, not otherwise specified

 

L7510

Repair of prosthetic device, repair or replace minor parts

 

L7520

Repair prosthetic device, labor component, per 15 minutes

 

L7700

Gasket or seal, for use with prosthetic socket insert, any type, each

 

L8400

Prosthetic sheath, below knee, each

 

L8410

Prosthetic sheath, above knee, each

 

L8417

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

 

L8420

Prosthetic sock, multiple ply, below knee, each

 

L8430

Prosthetic 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

 

HCPCS modifiers:     

K0 Functional Level 0

K1 Functional Level 1

K2 Functional Level 2

K3 Functional Level 3

K4 Functional Level 4

REFERENCES:

  1. Alaranta, H., Kinnunen, A., et al.  Practical benefits of flex-foot™ in below-knee amputees, Journal of Prosthetics and Orthotics 1991, Vol. 3, No. 4, pp. 179-181.
  2. Anzel, Stanford H., Perry, Jacquelin, et al.  Prosthetic design for dysvascular below-knee amputees, Department of Veterans Affairs, VA Rehabilitation Research and Development Service, Project #A735-RA, www.vard.org/prog/94/ch01/pr94020.htm.
  3. Anzel, Stanford H., Perry, Jacquelin, et al.  Prosthetic foot design for the dysvascular below-knee amputee, Department of Veterans Affairs, VA Rehabilitation Research and Development Service, Project #A735-RA, www.vard.org/prog/95/ch01/pr95024.htm.
  4. Beil TL, Street GM and covey SJ.  Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets.  Journal of Rehabilitation Research and Development, November/December 2002, Vol. 39, No. 6, pp. 693-700.
  5. Bodeau Valerie S, et al.  Lower limb prosthetics, August 27, 2002 www.emedicine.com/pmr/topic175.htm.
  6. Brunelli S, Delussu AS, Paradisi F, Pellegrini R, Traballesi M. A comparison between the suction suspension system and the hypobaric Iceross Seal-In® X5 in transtibial amputees. Prosthet Orthot Int. 2013;37(6):436-444.
  7. Centers for Medicare and Medicaid Services (CMS).  LCD for lower limb prostheses (L11442).  January 2010.
  8. Esquenazi, A., Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration, Disability and Rehabilitation, 2004; Vol 26, No. 14/15, 831-836.
  9. Fuller M, Luff, Robin, Boom MV. A novel approach to wound management and prosthetic use with concurrent vacuum-assisted closure therapy. Prosthetics and Orthotics International. 2011, 35(2) 246-249.
  10. Gholizadeh H, Lemaire ED, Sinitski EH, et al. Transtibial amputee gait with the unity suspension system. Disabil Rehabil Assist Technol. 2019 Feb 27:1-7 [Epub ahead of print].
  11. Hafner, B.J., Sanders, J.E., et al.  Energy storage and return prostheses:  Does patient perception correlate with biomechanical analysis, Clin Biomech (Bristol, Avon) June 2002; 17(5): 325-44.
  12. Hoskins RD, Sutton EE, Kinor D, et al. Using vacuum-assisted suspension to manage residual limb wounds in persons with transtibial amputation: A case series. Prosthet Orthot Int. 2014;38(1):68-74.
  13. Klute, Glenn K., et al.  Mechanical properties of prosthetic limbs:  Adapting to the patient, Journal of Rehabilitation Research and Development, May/June 2001, Vol. 38, No. 3, www.vard.org/jour/01/38/3/klute383.htm.
  14. Klute GK, Berge JS, Biggs W, et al. Vacuum-assisted socket suspension compared with pin suspension for lower extremity amputees: Effect on fit, activity, and limb volume. Arch Phys Med Rehabil. 2011;92(10):1570-1575.
  15. Macfarlane, Pamela A., et al.  Gait comparisons for below-knee amputees using a flex-foot ™ versus a conventional prosthetic foot, Journal of Prosthetics and Orthotics 1991, Vol. 3, No. 4, pp. 150-161.
  16. Macfarlane, Pamela A., et al.  Mechanical gait analysis of transfemoral amputees:  SACH foot versus the flex-foot, Journal of Prosthetics and Orthotics 1997, Vol. 9, No. 4, pp. 144-151.
  17. Macfarlane, Pamela A., et al.  Perception of walking difficulty by below-knee amputees using a conventional foot versus the flex-foot, Journal of Prosthetics and Orthotics 1991, vol. 3, No. 3, pp. 114-119.
  18. Macfarlane, Pamela A., et al.  Transfemoral amputee physiological requirements:  Comparisons between SACH foot walking and flex-foot [sic] walking, Journal of Prosthetics and Orthotics 1997, Vol. 9, No. 4, pp. 138-143.
  19. Martin CW; WCB Evidence Based Group. Otto Bock C-leg®: A review of its effectiveness for special care services. Assessment prepared for Workers Compensation Board of British Columbia, Compensation and Rehabilitation Services Division. Vancouver, BC: Workers Compensation Board of British Columbia; November 27, 2003.
  20. Menard, Michael R. and Murray, D. Duncan.  Subjective and objective analysis of an energy-storing prosthetic foot, Journal of Prosthetics and Orthotics, Vol. 1, No. 4, pp. 220-230.
  21. Menard, Michael R. et al.  Comparative biomechanical analysis of energy-storing prosthetic feet, Arch Phys Med Rehabil, May 1992, Vol. 73, pp. 451-458.
  22. Murphy D. Fundamentals of amputation care and prosthetics. New York, NY: Demos Medical Publishing, LLC; 2014.
  23. Pinzur MS. Prosthetic considerations. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. 2003. Chapter 64.
  24. Rink C, Wernke MM, Powell HM, et al. Elevated vacuum suspension preserves residual-limb skin health in people with lower-limb amputation: Randomized clinical trial. J Rehabil Res Dev. 2016;53(6):1121-1132.
  25. Rosenblatt NJ, Ehrhardt T. The effect of vacuum assisted socket suspension on prospective, community-based falls by users of lower limb prostheses. Gait Posture. 2017;55:100-103.
  26. Samitier CB, Guirao L, Costea M, et al. The benefits of using a vacuum-assisted socket system to improve balance and gait in elderly transtibial amputees. Prosthet Orthot Int. 2016;40(1):83-88.
  27. Sherman RA, Casey Jones DE. The amputees guide to the amputation and recovery process. Second edition, 1995. Accessed August 14, 2013. Available at URL address: http://www.fizjoterapeutom.pl/files/13/amputeeguide.pdf
  28. Thibault G, Gholizadeh H, Sinitski E, et al. Effects of the unity vacuum suspension system on transtibial gait for simulated non-level surfaces. PLoS One. 2018;13(6):e0199181.
  29. Traballesi M, Delussu AS, Fusco A, et al. Residual limb wounds or ulcers heal in transtibial amputees using an active suction socket system. A randomized controlled study. Eur J Phys Rehabil Med. 2012;48(4):613-623.
  30. www.palmettogba.com/palmetto/LMRPs_DMERC.nsf/9a111459ebdc924685256a76.

POLICY HISTORY:

Medical Policy Group, February 2003 (2)

Medical Policy Administration Committee, February 2003

Available for comment April 1-May 16, 2003

Medical Policy Group, July 2004

Medical Policy Administration Committee, August 2004

Available for comment August 12-September 25, 2004

Medical Policy Group, January 2006 (1)

Medical Policy Group, August 2006 (2)

Medical Policy Administration Committee, August 2006

Available for comment August 15-September 28, 2006

Medical Policy Group, April 2007 (2)

Medical Policy Administration Committee May 2007

Available for comment May 8-June 21, 2007

Medical Policy Group, August 2007 (3)

Medical Policy Administration Committee, August 2007

Available for comment September 27-November 13, 2007

Medical Policy Group, February 2009 (1)

Medical Policy Group, August 2010 (1) Added non-coverage statement for VASS, Key Points

Medical Policy Administration Committee, August 2010

Available for comment August 6-September 4, 20107700

Medical Policy Administration Committee, September 2010

Available for comment September 4-October 18, 2010

Medical Policy Group, October 2010

Medical Policy Group, December 2011(1): 2012 Code updates; Code L5311 was deleted and Code L5312 was added effective January 1, 2012.

Medical Policy Group, February 2015 (6):  2015 Updates – annual review of policy, cleaned up

coding section – removing deleted codes and adding new codes; no change to policy statement

Medical Policy Group, December 2017: Annual Coding Update 2017.  Added new HCPCS code L7700 to Current Coding.

Medical Policy Group, October 2018 (6): Updates to Description, Key Points and References. No change to policy intent.

Medical Policy Group, April 2020 (6) Updates to Policy to include hip prosthetics, Description, Key Points, Coding (L5961), Key Words (hip prosthetic) and References. No change to policy intent.

Medical Policy Group, May 2020 (6): Updated Policy to include coverage of specialized vacuum pump residual limb volume management and moisture evacuation systems (L5781/L5782) with criteria. Draft through June 15, 2020.

Medical Policy Group, July 2021 (6): Updates to Policy section socket coding, Key Points and Key Words. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.