Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Lower Limb Prostheses

Policy #:05.00.59i

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.
State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

A lower limb prosthesis is considered medically necessary and, therefore, covered when all of the following medical necessity criteria are met:
  • The individual has undergone amputation of the lower extremity.
  • The individual is motivated to ambulate.
  • The individual has a potential functional ability of Level 1 or greater (see the table below for the classifications of functional ability).
  • The prosthesis is prescribed by an eligible professional provider and fitted/made by an orthotist or prosthetist.

For individuals with unilateral lower extremity amputation, only one lower limb prosthesis is considered medically necessary and, therefore, covered.

FUNCTIONAL LEVELS

Determination of medical necessity for certain components/additions to the prosthesis is based on the individual's potential functional ability. Potential functional ability is based on the reasonable expectations of the prosthetist and the treating professional provider, considering factors that include, but are not limited to:
  • The individual's past history (including prior prosthetic use if applicable)
  • The individual's current condition (including the status of the residual limb and the nature of any other medical problems)
  • The individual's desire to ambulate

Clinical assessment of an individual's potential functional ability must be based on the following Medicare Functional Classification Level (MFCL) classification levels:


Level 0Does 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.
Level 1Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
Level 2Has the ability or potential for prosthetic ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.
Level 3Has the ability or potential for prosthetic 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 4Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.


TYPES OF PROSTHESES

The individual must meet all of the medical necessity criteria listed above in order for the types of prostheses listed below to be covered.

PREPARATORY/IMMEDIATE POSTOPERATIVE PROSTHESIS (IPOP)
Immediately following the amputation procedure, an IPOP (L5400, L5410, L5420, L5430, L5450, L5460) is considered medically necessary and, therefore, covered:
  • In the initial postoperative period, cast changes are necessary as the residual limb muscles atrophy, usually at seven- to ten-day intervals.

In the intermediate period between the amputation procedure and definitive prosthetic fitting, the following preparatory prostheses: L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600 are considered medically necessary and, therefore, covered:
  • The type of preparatory prosthesis used is based on the physician's clinical judgment, considering the status of the residual limb and the individual's history, current condition, and desire to ambulate.
    • This period of prosthetic utilization is defined by continued rapid changes in limb volume due to the initiation of ambulation and consistent prosthetic use.
    • Transition from a preparatory prosthesis should only occur with relative stabilization of the residual limb size and consistency of prosthetic fit for several months.

DEFINITIVE PROSTHESIS
A definitive prosthesis is considered medically necessary and, therefore, covered:
  • For an individual whose residual limb is no longer changing shape or volume
    • This period of prosthetic utilization is defined by relatively full residual limb maturation and stability (this occurs after an individual has utilized a preparatory prosthesis consistently for approximately six months and limb volume has stabilized, resulting in a relatively constant socket fit).
    • Component selection for the definitive prosthesis is based on the potential functional ability of the individual.

COMPONENTS OF A DEFINITIVE PROSTHESIS

PROSTHETIC FOOT COMPONENT
A basic lower extremity prosthesis includes a solid ankle cushion heel (SACH) foot. Other prosthetic feet are considered medically necessary and, therefore, covered based on the potential functional ability of the individual.
  • An external keel SACH foot (L5970) or single-axis ankle/foot (L5974) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 1 or above.
  • A flexible keel foot (L5972) or multiaxial ankle/foot (L5978) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 2 or above.
  • An energy-storing foot (L5976), a dynamic response (L5979), a flex-foot system (L5980), a flex-walk system or equal (L5981), or a shank foot system with vertical-loading pylon (L5987) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 3 or above.

PROSTHETIC ANKLE COMPONENT
An axial rotation unit (L5982, L5984, L5986) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 2 or above.

PROSTHETIC KNEE COMPONENT
A basic lower extremity prosthesis includes a single-axis, constant-friction knee. Other prosthetic knees are considered medically necessary and, therefore, covered based on the potential functional ability of the individual.
  • A high-activity knee control frame (L5930) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 4.
  • A fluid or pneumatic knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848) is considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 3 or above.
  • Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5814, L5816, L5818) are considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 1 or above.

PROSTHETIC HIP COMPONENT
A pneumatic or hydraulic polycentric hip joint (L5961) is covered for patients whose functional level is 3 or above.

PROSTHETIC SOCKET
  • Two test (diagnostic) sockets (L5618, L5620, L5622, L5624, L5626, L5628) per individual prosthesis are considered medically necessary and, therefore, covered. Requests for additional sockets require additional documentation.
    • Test sockets are considered not medically necessary and, therefore, not covered for IPOPs (L5400, L5410, L5420, L5430, L5450, L5460).
  • No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time. Additional inserts are considered not medically necessary and, therefore, not covered.
  • Socket inserts used in conjunction with a suspension locking mechanism (L5673, L5681, or L5683) are considered medically necessary and, therefore, covered. These include socket inserts with or without a distal umbrella adapter for attaching the pin/lanyard of the locking mechanism.
    • The suspension locking mechanism that is integrated into the prosthesis socket, the pin(s), and lanyard, or other component that is attached to the socket insert are addressed by code L5671. However, L5671 does not include the socket insert itself.
  • Socket replacements (custom or prefabricated, (L5673, L5679) are considered medically necessary and, therefore, covered if there is adequate documentation of functional and/or physiological need. Documentation may include, but is not limited to: changes in the residual limb, functional need changes, or irreparable wear-and-tear damage due to excessive patient weight or prosthetic demands of very active amputees.

SHOES
  • Shoes (L3250) are considered medically necessary and, therefore, covered if they are an integral part of a covered lower limb prosthesis and are medically necessary for the proper functioning of the prosthesis.
  • A shoe (L3250) that is billed as a replacement for a previously covered shoe and is an integral part of an existing lower limb prosthesis for an individual with a partial foot amputation is considered medically necessary and, therefore, covered. In such cases, the item must meet the requirements included in the Company's policy on repair and replacement of external prosthetic devices.
  • A shoe is considered not medically necessary and, therefore, not covered for any other condition or if billed in any manner (eg, separately, simultaneously with the prosthesis) other than as a replacement shoe for an existing lower limb prosthesis.

ACCESSORIES (EG, STUMP STOCKINGS, HARNESSES)
  • Accessories are considered medically necessary and, therefore, covered when they are essential to, or aid in, the effective use of a covered lower limb prosthesis that meets the medical necessity criteria listed in this policy (L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5672, L5676, L5677, L5678, L5680, L5682, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5704, L5705, L5706, L5707, L7367, L7368, L8400).

TRANSTIBIAL (BELOW-KNEE) PROSTHESES

When an initial below-knee prosthesis (L5500) or a preparatory below-knee prosthesis (L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are considered medically necessary and, therefore, covered in accordance with the functional level assessment of the individual. However, the accessories represented by HCPCS codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 are not intended for use with an initial or preparatory below-knee prosthesis. If these codes are reported in conjunction with an initial or preparatory below-knee prosthesis, they will be denied as not medically necessary.

When a below-knee preparatory prefabricated prosthesis (L5535) is provided, prosthetic substitutions and/or additions of procedures and components are considered medically necessary and, therefore, covered in accordance with the functional level assessment of the individual. However, the accessories represented by HCPCS codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962 are not intended for use with a below-knee preparatory prefabricated prosthesis. If these codes are reported in conjunction with a below-knee preparatory prefabricated prosthesis, they will be denied as not medically necessary.

TRANSFEMORAL (ABOVE-KNEE) PROSTHESES

When an initial above-knee prosthesis (L5505) or a preparatory above-knee prosthesis (L5560, L5570, L5580, L5590, L5595, L5600) is provided, prosthetic substitutions and/or additions of procedures and components are considered medically necessary and, therefore, covered in accordance with the functional level assessment of the individual. However, the accessories represented by HCPCS codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5790, L5795, L5964, and L5980 are not intended for use with an initial or preparatory above-knee prosthesis. If these codes are reported in conjunction with an initial or preparatory above-knee prosthesis, they will be denied as not medically necessary.

When an above-knee preparatory prefabricated prosthesis (L5585) is provided, prosthetic substitutions and/or additions of procedures and components are considered medically necessary and, therefore, covered in accordance with the functional level assessment of the individual. However, the accessories represented by HCPCS codes L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966 are not intended for use with an above-knee preparatory prefabricated prosthesis. If these codes are reported in conjunction with an above-knee preparatory prefabricated prosthesis, they will be denied as not medically necessary.

REPAIR AND REPLACEMENT

For information on the repair and/or replacement of prostheses, refer to the Company's policy on the repair and replacement of external prosthetic devices.

The repair or replacement of lower limb prostheses or one or more of its components (parts) is considered noncovered and not eligible for reimbursement when the request is for a technologically advanced or newly released upgrade to an original device that still functions properly and/or there is no significant change in the individual's condition.

Additionally, repair and replacement is not covered if either the device itself or one or more of its components (parts) is under a manufacturer's warranty. In this case, it is the individual's responsibility to arrange the repair or replacement of an external prosthetic device with the manufacturer while the device is under warranty.

Requests for a different type of lower limb prostheses or one or more of it components (parts) due to a change in medical and/or functional status, such that the lower limb prostheses can no longer meet the individual’s needs for control, durability (maintenance), function (speed, work capability), and usability are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the new type of lower limb prostheses requested.

The Company may determine the reasonable useful lifetime of a specific external prosthetic device based on the manufacturer's recommendation or the Food and Drug Administration (FDA)--approved labeling.

In the absence of manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific external prosthetic device, but is generally not less than five years. Replacement due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

NOT MEDICALLY NECESSARY

A lower limb prosthesis is considered not medically necessary and, therefore, not covered for an amputee whose potential functional ability is at Level 0.

If a prosthesis is considered not medically necessary, all related components and accessories for that prosthesis are also considered not medically necessary and, therefore, not covered.

Components and/or accessories for a prosthesis that do not serve a functional purpose are considered not medically necessary and, therefore, not covered.

STATE OF NEW JERSEY MANDATE

NEW JERSEY COMMERCIAL MEMBERS
In accordance with the State of New Jersey's orthotic and prosthetic appliances mandate, members who are enrolled in New Jersey commercial products may obtain a lower limb prosthesis from any licensed orthotist or prosthetist or certified pedorthotist, as determined medically necessary by the covered member's physician.

BILLING REQUIREMENTS

The right (RT) and left (LT) modifiers must be used when reporting prosthesis codes. When the same codes for prostheses, sockets, or components for bilateral amputees are billed on the same date of service, the items must be entered on the same line of the claim form, using the appropriate RT/LT modifiers, and billed for two units of service.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

Reimbursement for devices will be made only if there is sufficient documentation in the individual's medical record showing current functional capabilities and functional need for the technologic or design features. Documentation should also include expected functional potential and an explanation if there is a difference between the individual's current status and expected potential. This information must be retained in the professional provider's or prosthetist's files, and be available upon request.

The prosthetist must retain documentation in the medical record of the prosthesis or prosthetic component replaced, the reason for replacement, and a description of the labor involved. It is recognized that there are situations where the reason for replacement includes but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive weight or prosthetic demands of highly mobile amputees.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, lower limb prostheses are covered as prosthetics under the medical benefits of most of the Company’s products when the medical necessity criteria listed in this medical policy are met. Individual member benefits must be verified.

Coverage and reimbursement for the repair and/or replacement of external prosthetic devices vary by product and/or group contract. Therefore, individual member benefits must be verified. For more information, refer to the Company's policy on the repair and replacement of external prosthetic devices.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA considers lower limb prostheses to be Class I or Class II devices that are exempt from premarket notification procedures. Therefore, the FDA does not regulate these products.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state in which the group benefit contract is issued determine the applicable legislatively mandated coverage.
  • The State of New Jersey mandates coverage of prosthetics for individuals enrolled in New Jersey commercial products when such items are determined to be medically necessary by the individual's physician. This mandate is effective for all newly issued contracts and contracts renewed on or after April 11, 2008.


Description

A lower limb prosthesis is an artificial lower extremity for an individual who has sustained an amputation due to complications of disease or trauma. The type of prescribed prosthesis is dependent on the functional level of the recipient and is geared toward replacing the function of a lower extremity, providing comfort, and minimizing limitations.

GENERAL PROSTHETIC DESIGNS

There are two basic types of prosthetic designs, and, although they are made differently, they provide many of the same functions.
  • Exoskeletal prostheses: This design is typically composed of wood or urethane foam interiors and an outer plastic-laminated skin or shell.
  • Endoskeletal prostheses: This design utilizes aluminum, titanium, graphite, and other tubular material to form the supporting interior structure with a flexible foam cover that is cosmetically topped with a nylon hose.

COMPONENT PARTS OF A LOWER LIMB PROSTHESIS

All lower limb prostheses generally have the following components:
  • Socket: The custom-made top portion that fits around the residual limb. Socket designs vary depending on the level of amputation, the needs of the amputee, and the resulting materials selected for fabrication of the socket. Most sockets are custom fabricated directly from molds or based upon empirical data about an amputee's residual limb. Some prefabricated and volume-adjustable sockets are available; these are most often used in the early fitting stages. The socket is secured to the amputee's residual limb by a number of methods that can include a belt, a sleeve, or other techniques such as suction within the socket or a tight fit around the condyles of the residual limb.
  • Foot: The bottom or terminal portion of the prosthesis that contacts the ground. There is an abundance of prosthetic foot designs available, with a range of functional characteristics to suit the functional level of the amputee. Most feet attach solidly to the shank (shin) and do not require a moveable ankle unit; these feet simulate ankle motion in their function. Some feet require ankle units, whereas others are functionally enhanced by these units.

Additional lower limb components:
  • Prostheses for transtibial (below the knee) amputees and higher levels include:
    • Shank (shin) -- The portion connecting the foot and ankle (if used) to the upper prosthesis, usually to the socket of the knee unit. In exoskeletal prostheses, the shank is tubular, usually aluminum or graphite, with either stainless steel or titanium connectors at the foot and socket or knee. The connectors generally have alignment capability, even after the prosthesis is fabricated and finished.
  • Prostheses for knee disarticulation (through the knee) amputees and higher levels include:
    • Knee -- This component bends (flexes) and straightens (extends) to allow for standing, normal walking, sitting, and kneeling.
  • Prostheses for transfemoral (above the knee) amputees and higher levels include:
    • Thigh -- The component between the top of the knee and the bottom of the socket in transfemoral amputees, or to the hip joint in higher level amputees.
  • Prostheses for hip disarticulation (at the hip) and higher levels include:
    • Hip joint -- This hinged component bends (flexes) and straightens (extends) to allow for standing, walking, and sitting.

TYPES OF PROSTHETIC DEVICES
  • An immediate postoperative (IPOP)/preparatory/initial prosthesis is an initial prosthetic typically fitted postoperatively to facilitate proper residual limb shaping, edema reduction, and, in select cases, to provide assistance with early weight-bearing. An IPOP also promotes the individual's tolerance for prostheses, ultimately preparing the individual for the fitting of a definitive prosthesis once residual limb stabilization has been achieved. This prosthesis includes a cast, a pylon, and a foot; as the residual limb begins to conform to the socket, adjustments are made to the components to encourage proper alignment, function, and tolerance. There are four types of preparatory prostheses: plaster-molded, thermoplastic direct form, thermoplastic-molded, and laminated-molded-to-model.
  • A definitive prosthesis is a prosthetic that is fitted once the individual achieves residual limb volume stabilization. Built for long-term use, it provides comfort, alignment, function, and durability.

References


American Academy of Orthotists and Prosthetists. Standards of care. JPO.2004;16(3S):6-12. Also available at: https://journals.lww.com/jpojournal/Fulltext/2004/07001/STANDARDS_OF_CARE.3.aspx. Accessed November 5, 2018.

Consumer Guide for Amputees: A Guide to Lower Limb Prosthetics: Part I -- Prosthetic Design: Basic Concepts. Available at:http://www.amputee-coalition.org/inmotion/mar_apr_98/pros_primer/page1.html. Accessed November 5, 2018.

Noridian. Local Coverage Determination (LCD).L33787: Lower limb prostheses. Original: 10/01/2015. (Revised: 01/01/18). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed November 5, 2018.

New Jersey (NJ) Legislature. P.L. 2007, Chapter 345. Senate No. 502. Requires health benefits coverage by health insurers and SHBP for orthotic and prosthetic appliances and provides reimbursement. [NJ State Legislature Web site]. 01/13/08. Available at: http://www.njleg.state.nj.us/2006/Bills/AL07/345_.PDF. Accessed November 5, 2018.

Noridian. Article A52496, Lower limb Prostheses. Original 10/01/2015. (Revised 01/01/2018). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active.
Accessed November 5, 2018.

Noridian LCD L33641, Orthopedic Footwear. [NHIC Web site]. Original:10/01/2015. (Revised 01/01/2017). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed November 5, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A.


Revenue Code Number(s)

N/A


Misc Code

HCPCS Modifiers:

FUNCTIONAL LEVEL MODIFIERS

K0 Lower extremity prosthesis functional level 0-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

K1 Lower extremity prosthesis functional level 1 - has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator.

K2 Lower extremity prosthesis functional 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.

K3 Lower extremity prosthesis functional 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

K4 Lower extremity prosthesis functional level 4 - has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete.


LT - Left side

RT - Right side

RA - Replacement of a DME, orthotic or prosthetic item

RB - Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair



Coding and Billing Requirements


Cross References

Attachment A: Lower Limb Prostheses
Description: HCPCS Level II Code Number(s) and Narrative(s)




Policy History

05.00.59i:
12/19/2018This policy has been reviewed and reissued to communicate the Company’s continuing position on Lower Limb Prostheses.
01/01/2018This policy has been identified for the HCPCS code update, effective 01/01/2018.

The following HCPCS codes have been added to this policy:
  • L7700 Gasket or seal, for use with prosthetic socket insert, any type, each

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: 12/19/2018

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.