coverage guidelines prosthetics - baptist health plan · prosthetics (mp)”. implantable fda...

Prosthetics Created: 09/01/04

Updated: 06/02/15 (mba); 05/10/12; 02/26/08; 03/20/07; 11/21/05 Coded: 08/30/15 (sbm)

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Copyright 2012 Healthcare Research & Resolutions. This information is not intended to replace the advice of a healthcare professional or an attorney.

Coverage Guidelines

Prosthetics

Disclaimer:

Please note that Baptist Health Plan updates Coverage Guidelines throughout the year. A printed version may not be most up to date version available. The health plan reserves the right to review and update this policy as needed. Refer to the website to ascertain that you are utilizing the most current available version. Clinical guideline policies are not intended to serve as treatment guidelines or treatment recommendation. Treating providers must use their own clinical judgment in rendering care to their patient population.

For self-funded plans, consult individual plan documents. If there is a conflict between this policy and a self-funded plan document, the provisions of the plan document will govern. In addition, coverage for Medicare Advantage members may differ. This is a result of applicable coverage statements by the Center for Medicare & Medicaid Services (CMS). The National Coverage Determinations, Local Coverage Determinations, and Local Medical Review Policies may be found at the CMS website: http://www.cms.gov. Please note that for all plans, the member’s health plan benefits that are in effect on the rendered date of service must be used in coverage determinations.

Breast prostheses are discussed in the Coverage Guideline titled “Breast Surgeries”.

Myoelectric prostheses are discussed in the Coverage Guideline titled “Myoelectric Prosthetics (MP)”.

Implantable FDA approved prosthetics being used as part of an approved surgical procedure are not addressed in this paper.

DEFINITION

A prosthetic is an artificial substitute for a body part or a material inserted into tissue for functional, cosmetic, or therapeutic purposes. Prostheses may be functional, as in the case of arms, legs, feet, and ankles or hip and knee replacement joints, or cosmetic, as in the case of an artificial eye or breast prosthesis. Implanted prosthetics tend to be used therapeutically and are surgically inserted or grafted into the body.i

The terms Medically Necessary (or Medical Necessity) are defined by the Plan as the services or supplies required and/or furnished by a Provider to identify or treat a Member’s illness or injury and which, as determined by the Plan, are:

• Consistent with the symptom or diagnosis and treatment of the Member’s condition, disease, ailment, or injury;



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• Appropriate with regard to standards of good medical practice;

• Not solely for the convenience of a Member or Provider; and

• The most appropriate supply or level of service that can be safely provided to the Member. When applied to the care of an Inpatient, it further means that the Member’s medical symptoms or condition require that the services cannot be safely provided as an Outpatient.

Examples of available prosthetics include but may not be limited to:

• Ankle

• Arm

• Breast Prosthesis

• Ears

• Eyes

• Facial Prosthesis (such as nose, lips)

• Fingers / Thumbs / Toes

• Foot

• Hand / Partial Hand

• Hip

• Knee

• Leg

• Testicles

• Wigs

Although some prosthetics are used to restore functionality or body structure, others are purely cosmetic.

COVERAGE CRITERIA

In accordance with the Centers for Medicare and Medicaid Services, the Plan considers ostomy supplies and urinary collection and retention systems, and tracheostomy supplies to be related to the functioning of a prosthetic. Therefore, ostomy and urinary supplies are subject to the “Plan’s” provisions for prosthetics.

Prosthetic purchases and replacements require pre-certification.

Medically Necessary Prosthetics

The initial purchase, fitting, necessary adjustments, repairs, and replacements of prosthetics that replace a limb or a permanently inoperative or malfunctioning external body part may be considered medically necessary as detailed below:

• A preparatory (initial) prosthesis for the first several weeks or months following surgery until



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the stump has stabilized and the “permanent” or definitive prosthesis is provided

• Training is usually necessary for optimum prosthetic performance and comfort. Early training is provided by the prosthetist during the fitting trials. Additional training by a physical therapist is available up to the COC provisions limit for physical therapy visits.

• Purchase, fitting, necessary adjustments, and repairs of prosthetic devices and supplies to restore minimal basic function or replace all or part of the function of a permanently inoperative or malfunctioning body part or an absent body part (including contiguous tissue)

• Replacement of a prosthetic device required by a change in medical condition or to accommodate growth

• Replacement of a prosthetic that is non-functional due to normal wear and tear and is no longer serviceable

• Prostheses must be ordered or provided by, or under the direction of a physician

• Batteries useful to, and required for approved prosthetics

If more than one prosthetic device can meet the Member’s functional needs, only the most cost-effective prosthetic device is considered medically necessary.

The following specific prosthetics may be medically necessary when criteria are met:

• Eye – includes one enlargement or reduction of the prosthesis in addition to polishing and resurfacing twice a year

• Facial – including ears

• Lower limb – (a basic prosthetic for a Member at a K1 level usually includes a SACH foot and a single axis, constant friction knee) – when ALL the following criteria are met:

� Prosthesis is needed for ambulation

� Member can be expected to reach or maintain functional use within a reasonable period of time

� Medical records are available documenting current functional capabilities and rehabilitation potential is based on the K levels outlined below in the Medical Background section of this document

• SPECIFIC lower limb information:

� Ankle – Member is at a functional level (see chart below in Medical Background section) of:

o K2 or above may be eligible for an axial rotation unit

o K3 or above may be eligible for an endoskeletal ankle/foot or a power-assist ankle system

� Foot – Member is at a functional level of:

o K1 or above may be eligible for an external keel SACH (Solid Ankle Cushion



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Heel) foot or a single axis ankle/foot or a flexible-keel foot or a multiaxial ankle/foot

o K2 or above may be eligible for a flexible-keel foot or multi-axial ankle/foot

o K3 or above functional level may be eligible for a flex foot system. Energy storing foot, multi-axial ankle/foot, dynamic response or flex-walk system

� Knee – Member is at a functional level of:

o K1 or above may be eligible for a single axis constant friction knee and other basic knee systems

o K3 or above may be eligible for a fluid or pneumatic knee

o K4 or above may be eligible for a high-activity knee control frame

• Upper Extremity

� A body-powered upper extremity prosthesis may be medically necessary when this type of prosthesis meets the functional needs to perform normal activities of daily living (ADLs)

• Testicular ii

Prosthetics that may NOT be medically necessary, or are excluded by the Plan, and/or may be considered experimental/investigational include but may not be limited to:

• Batteries that are considered common household items and are readily available over-the-counter

• Batteries necessary for use in non-covered prosthetics

• Replacement of a prosthetic device that has been lost or stolen, or was broken by carelessness, abuse or lack of maintenance is excluded by the Plan

• Replacement of a prosthetic for appearance or for a newer model with additional features is excluded by the Plan

• Dental appliances, other than those required in treatment of TMJ or CMJ, are excluded by the Plan (To be considered medically necessary dental appliances used in the treatment of TMJ/CMJ must not be designed to change the position of the teeth. If an appliance changes the position of the Member’s teeth it is considered to be an orthodontic treatment and is excluded by the Plan regardless of medical necessity.)

• For Members who do not have the ability or potential to ambulate or transfer safely with or without assistance, and when a prosthesis would not enhance their quality of life or mobility, a prosthetic is excluded by the Plan

• A second prosthetic for back-up purposes is excluded by the Plan

• Wigs are excluded by the Plan

• A user-adjustable heel height feature for a foot prosthesis



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• Proprio Foot (Össur)iii

• Test (diagnostic) sockets for immediate post-surgical or early-fitted prostheses

• The Vacuum Assisted Socket System (VASS), a device used in conjunction with artificial limbs. VASS is considered experimental and investigational. Despite use of VASS the pain and wound healing did not significantly differ from the control group. iv

• Microprocessor-controlled leg prostheses such as the OttoBock C-Leg or the Össur Rheo Knee

A Member’s potential functional ability when provided with a lower limb prosthetic may be determined by the following K Levels. These levels, as defined by Medicare, determine the prosthetic most appropriate for the Member.

K-Level Outcome Measures in Lower Limb Prostheticsv

K-Level Description

K0 Member does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Therefore, a Member at this level would not be eligible for a prosthesis.

K1 Member has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence. A Member at this level is considered a typical limited community ambulatory.

K2 Member has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. A Member at this level is considered a typical community ambulatory

K3 Member has the ability or potential for ambulation with variable cadence. At this level a Member is considered a typical community ambulatory with the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple locomotion.

K4 Member has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact stress, or energy levels. This K-level is typical of the prosthetic demands of a child, active adult or an athlete.

Upper limb prostheses are classified as follows:

Body powered – A body harness and cable system provides functional manipulation. The voluntary movement of the shoulder and/or limb stump extends the cable system transmitting force to the device to control hand, forearm and elbow movement.

Passive – The lightest system is a mostly cosmetic prosthesis. It must be repositioned manually by the opposite arm.



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REGULATORY INFORMATION

Kentucky – No legislative mandates were found for coverage of prosthetics.

Indiana – No legislative mandates were found for coverage of prosthetics.

Tennessee – No legislative mandates were found for coverage of prosthetics.

Prosthetic devices are subject to regulation by the U.S. Food and Drug Administration (FDA) as medical devices.

COVERAGE DETAIL

CODES INCLUDE BUT MAY NOT BE LIMITED TO THE FOLLOWING:

CPT© Codes

Description Coverage Information

21076 Impression and custom preparation; surgical obturator prosthesis

May be medically necessary when criteria are met

21077 Impression and custom preparation; orbital prosthesis May be medically necessary when criteria are met

21079 Impression and custom preparation; interim obturator prosthesis


21080 Impression and custom preparation; definitive obturator prosthesis


21081 Impression and custom preparation; mandibular resection prosthesis


21082 Impression and custom preparation; palatal augmentation prosthesis


21083 Impression and custom preparation; palatal lift prosthesis May be medically necessary when criteria are met

21084 Impression and custom preparation; speech aid prosthesis May be medically necessary when criteria are met



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21085 Impression and custom preparation; oral surgical splint May be medically necessary when criteria are met

21086 Impression and custom preparation; auricular prosthesis May be medically necessary when criteria are met

21087 Impression and custom preparation; nasal prosthesis May be medically necessary when criteria are met

21088 Impression and custom preparation, facial prosthesis May be medically necessary when criteria are met

97761 Prosthetic training, upper and/or lower extremity(s) each 15 minutes


97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes


HCPCs© Codes

Description Coverage Information

A4364 Adhesive, liquid, or equal, any type, per ounce May NOT be medically necessary, or may be excluded by the Plan

A4456 Adhesive remover, wipes, any type, each May NOT be medically necessary, or may be excluded by the Plan

A9282 Wig, any type, each May NOT be medically necessary, or may be excluded by the Plan

L5000 Partial foot, shoe insert with longitudinal arch, toe filler May be medically necessary when criteria are met

L5010 Partial foot, molded socket, ankle height, with toe filler May be medically necessary when criteria are met



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L5020 Partial foot, molded socket, tibial tubercle height, with toe filler


Ankle

L5050 Ankle, Symes, molded socket, solid ankle cushion heel (SACH) foot


L5060 Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot


Below Knee

L5100 Below knee, molded socket, shin, SACH foot May be medically necessary when criteria are met

L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot


Knee Disarticulation

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


Above 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


Hip Disarticulation

L5250 Hip disarticulation, Canadian type; molded socket, hip joint, May be medically



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single axis constant friction knee, shin, SACH foot necessary when criteria are met

L5270 Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot


Hemipelvectomy

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


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


Immediate Postsurgical or Early Fitting Procedures

L5400 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change, below knee


L5410 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment


L5420 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change “AK” or knee disarticulation


L5430 Immediate postsurgical 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 postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee


L5460 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee

May be medically necessary when



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criteria are met

Initial Prosthesis

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


Preparatory Prosthesis

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, thermoplastic or equal, direct formed


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




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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


Additions: Lower Extremity

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, endoskeletal 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 or below knee, each


L5618 Addition to lower extremity, test socket, Symes May be medically necessary when criteria are met

L5620 Addition to lower extremity, test socket, below knee May be medically necessary when criteria are met

L5622 Addition to lower extremity, test socket, knee disarticulation May be medically necessary when criteria are met

L5624 Addition to lower extremity, test socket, above knee May be medically necessary when criteria are met

L5626 Addition to lower extremity, test socket, hip disarticulation May be medically necessary when criteria are met



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L5628 Addition to lower extremity, test socket, Hemipelvectomy May be medically necessary when criteria are met

L5629 Addition to lower extremity, below knee, acrylic socket May be medically necessary when criteria are met

L5630 Addition to lower extremity, Symes type, expandable wall socket

Medically necessary when criteria are met

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 May be medically necessary when criteria are met

L5638 Addition to lower extremity, below knee, leather socket May be medically necessary when criteria are met

Additions: Socket Variations

L5639 Addition to lower extremity, below knee, wood socket May be medically necessary when criteria are met

L5640 Addition to lower extremity, knee disarticulation, leather socket


L5642 Addition to lower extremity, above knee, leather socket May be medically necessary when criteria are met

L5643 Addition to lower extremity, hip disarticulation, flexible inner socket, external frame


L5644 Addition to lower extremity, above knee, wood socket May be medically necessary when



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criteria are met

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 May be medically necessary when criteria are met

L5648 Addition to lower extremity, above knee, air, fluid, gel or equal, 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)




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L5661 Addition to lower extremity, socket insert, multidurometer, Symes


L5665 Addition to lower extremity, socket insert, multidurometer, below knee


L5666 Addition to lower extremity, below knee, cuff suspension May be medically necessary when criteria are met

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


Additions: Socket Insert and 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 Addition to lower extremity, below knee, knee joints, single axis, pair


L5677 Addition to lower extremity, below knee, knee joints, polycentric, pair


L5678 Addition to lower extremity, below knee, joint covers, pair May be medically necessary when criteria are met

L5679 Addition to lower extremity, below knee/above knee, custom fabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism


L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded




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criteria are met

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 that 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 May be medically necessary when criteria are met

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




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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 May be medically necessary when criteria are met

Replacements

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 SACH foot, replacement only


L5704 Custom shaped protective cover, below knee May be medically necessary when criteria are met

L5705 Custom shaped protective cover, above knee May be medically necessary when criteria are met

L5706 Custom shaped protective cover, knee disarticulation May be medically necessary when criteria are met

L5707 Custom shaped protective cover, hip disarticulation May be medically necessary when criteria are met

L5710 Addition, exoskeletal knee-shin system, single axis, manual lock


L5711 Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material




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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


Additions: Exoskeletal Knee-Shin System

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


Component Modification

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)




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criteria are met

L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)


Additions: Endoskeletal Knee-Shin System

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 May be medically necessary when



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feature, adjustable criteria are met

L5848 Addition to endoskeletal, knee-shin system, hydraulic 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


L5856 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

May NOT be medically necessary, or may be experimental / investigational

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


L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)


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 May be medically



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material (titanium, carbon fiber or equal) necessary when criteria are met

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


L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)


L5970 All lower extremity prostheses, foot, external keel, SACH foot


L5971 All lower extremity prosthesis, SACH foot, replacement only


L5972 All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)


L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source


L5974 All lower extremity prostheses, foot, single axis ankle/foot May be medically necessary when criteria are met

L5975 All lower extremity prostheses, combination single axis ankle and flexible keel foot




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criteria are met

L5976 All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)


L5978 All lower extremity prostheses, foot, multi-axial ankle/foot May be medically necessary when criteria are met

L5979 All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system


L5980 All lower extremity prostheses, flex-foot system May be medically necessary when criteria are met

L5981 All lower extremity prostheses, flex-walk system or equal May be medically necessary when criteria are met

L5982 All exoskeletal lower extremity prostheses, axial rotation unit


L5984 All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability


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 prosthesis, 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 May NOT be medically necessary, or may be experimental / investigational



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Prosthetics – Upper Limb

Partial Hand

L6000 Partial hand, Robin-Aids, thumb remaining (or equal) May be medically necessary when criteria are met

L6010 Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)


L6020 Partial hand, Robin-Aids, no finger remaining (or equal) May be medically necessary when criteria are met

L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)


Wrist Disarticulation

L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad


L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad


Below Elbow

L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad


L6110 Below elbow, molded socket (Muenster or Northwestern suspension types)


L6120 Below elbow, molded double wall split socket, step-up hinges, half cuff


L6130 Below elbow, molded double wall split socket, stump activated locking hinge, half cuff


Elbow disarticulation

L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm




of 30


criteria are met

L6205 Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm


Above Elbow

L6250 Above elbow, molded double wall socket, internal locking elbow, forearm


Shoulder Disarticulation

L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm


L6310 Shoulder disarticulation, passive restoration (complete prosthesis)


L6320 Shoulder disarticulation, passive restoration (shoulder cap only)


Interscapular Thoracic

L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm


L6360 Interscapular thoracic, passive restoration (complete prosthesis)


L6370 Interscapular thoracic, passive restoration (shoulder cap only)


Immediate and Early Postsurgical Procedures

L6380 Immediate postsurgical or early fitting, application of rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow


L6382 Immediate postsurgical or early fitting, application of rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or above elbow


L6384 Immediate postsurgical or early fitting, application of rigid dressing, including fitting alignment and suspension of components, and one cast change, shoulder




of 30


disarticulation or interscapular thoracic criteria are met

L6386 Immediate postsurgical or early fitting, each additional cast change and realignment


L6388 Immediate postsurgical or early fitting, application of rigid dressing only


Endoskeletal: Below Elbow

L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping


Endoskeletal: Elbow Disarticulation

L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping


Endoskeletal: Above Elbow

L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping


Endoskeletal: Shoulder Disarticulation

L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping


Endoskeletal: Interscapular Thoracic

L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping


L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, “USMC” or equal pylon, no cover, molded to patient model


L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, “USMC” or equal pylon, no cover, direct formed


L6584 Preparatory, wrist disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, “USMC” or equal




of 30


pylon, no cover, molded to patient model

L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, “USMC” or equal pylon, no cover, direct formed


L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, “USMC” or equal pylon, no cover, molded to patient model


L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, “USMC” or equal pylon, no cover direct formed


Additions: Upper Limb

L6600 Upper extremity additions, polycentric hinge, pair May be medically necessary when criteria are met

L6605 Upper extremity additions, single pivot hinge, pair May be medically necessary when criteria are met

L6610 Upper extremity additions, flexible metal hinge, pair May be medically necessary when criteria are met

L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type


L6615 Upper extremity addition, disconnect locking wrist unit May be medically necessary when criteria are met

L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, each


L6620 Upper extremity addition, flexion/extension wrist unit, with or without friction


L6621 Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device


L6623 Upper extremity addition, spring assisted rotational wrist May be medically necessary when



of 30


unit with latch release criteria are met

L6624 Upper extremity addition, flexion/extension and rotation wrist unit


L6625 Upper extremity addition, rotation wrist unit with cable lock


L6628 Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal


L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal


L6630 Upper extremity addition, stainless steel, any wrist May be medically necessary when criteria are met

L6632 Upper extremity addition, latex suspension sleeve, each May be medically necessary when criteria are met

L6635 Upper extremity addition, lift assist for elbow May be medically necessary when criteria are met

L6637 Upper extremity addition, nudge control elbow lock May be medically necessary when criteria are met

L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow


L6639 Upper extremity addition, heavy duty feature, any elbow May be medically necessary when criteria are met

L6640 Upper extremity additions, shoulder abduction joint, pair May be medically necessary when criteria are met

L6641 Upper extremity addition, excursion amplifier, pulley type May be medically necessary when criteria are met

L6642 Upper extremity addition, excursion amplifier, lever type May be medically necessary when criteria are met



of 30


L6645 Upper extremity addition, shoulder flexion-abduction joint, each


L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system


L6647 Upper extremity addition, shoulder lock mechanism, external powered actuator


L6648 Upper extremity addition, shoulder lock mechanism, external powered actuator


L6650 Upper extremity addition, shoulder universal joint, each May be medically necessary when criteria are met

L6655 Upper extremity addition, standard control cable, extra May be medically necessary when criteria are met

L6660 Upper extremity addition, heavy duty control cable May be medically necessary when criteria are met

L6665 Upper extremity addition, Teflon, or equal, cable lining May be medically necessary when criteria are met

L6670 Upper extremity addition, hook to hand, cable adapter May be medically necessary when criteria are met

L6672 Upper extremity addition, harness, chest or shoulder, saddle type


L6675 Upper extremity addition, harness, (e.g. figure of eight type), single cable design


L6676 Upper extremity addition, harness (e.g. figure of eight type) for dual cable design


L6677 Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow


L6680 Upper extremity addition, test socket, wrist disarticulation May be medically



of 30


or below elbow necessary when criteria are met

L6682 Upper extremity addition, test socket, elbow disarticulation or above elbow


L6684 Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic


L6686 Upper extremity addition, suction socket May be medically necessary when criteria are met

L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation


L6688 Upper extremity addition, frame type socket, above elbow or elbow disarticulation


L6689 Upper extremity addition, frame type socket, shoulder disarticulation


L6690 Upper extremity addition, frame type socket, interscapular-thoracic


L6691 Upper extremity addition, removable insert, each May be medically necessary when criteria are met

L6692 Upper extremity addition, silicone gel insert or equal, each


L6693 Upper extremity addition, locking elbow, forearm counterbalance


L6694 Addition to upper extremity prosthesis, below elbow/ above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism


L6695 Addition to upper extremity prosthesis, below elbow/ above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism




of 30


L6696 Addition to upper extremity prosthesis, below elbow/ above elbow, 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 L6694 or L6695


L6697 Addition to upper extremity prosthesis, below elbow/ above elbow, 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 L6694 or L6695


L6698 Addition to upper extremity prosthesis, below elbow/ above elbow, lock mechanism, excludes socket insert


Terminal Devices

Hooks

L6703 Terminal device, hook, Dorrance or equal, model #3 May be medically necessary when criteria are met

L6704 Terminal device sport/recreational/work attachment, any material, any size


L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined


L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined


L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size


L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size


L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric


L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric




of 30


L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric


L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric


L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement


L6721 Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined


L6722 Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined


REFERENCES

i The Free Medical Dictionary web site. Prosthetics. Available at: http://www.thefreedictionary.com/prosthetics. Accessed April 10, 2015. ii Turek PJ, Master VA, et al. Safety and efficacy of a new saline filled prosthesis. J Urol. 2004;172(4):1427-1430. iii Hayes, Inc. web site. Search & Summary. Proprio Foot (Össur). July 8, 2013. Available to subscribers at: www.hayesinc.com. Accessed April 23, 2015. iv 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. v American Academy of Orthotists & Prosthetists web site. Outcome measures in lower limb prosthetics. Available at: www.oandp.org. Accessed April 20, 2015.

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