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Lower Limb Prostheses
05.00.59s

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Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to all plans; therefore, individual 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 a lower extremity or has congenital absence or malformation 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 or unilateral congenital absence or malformation of the lower extremity, only one lower limb prosthesis is considered medically necessary and, therefore, covered. 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.

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 7- to 10-day intervals.
In the intermediate period between the amputation procedure and definitive prosthetic fitting, the following preparatory prostheses are considered medically necessary and, therefore, covered​: L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600.
  • 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 when either of the following criteria are met:
  • 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 6 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.
  • ​For an individual who is at a functional mobility level of K3 or above and is receiving an approved microprocessor knee (see Cross-Reference Policy section)​
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, L5841, 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.
  • Ultra-Light Materials- Codes L5940, L5950, and L5960 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis. They are not used for ultralight materials used in other components of a prosthesis – e.g., knee/shin system, pylon, ankle, foot. The unit of service for codes L5940, L5950, and L5960 is one per limb.
  • Acrylic Socket- L5629 and L5631 describe an addition to a prosthetic socket. The fabrication includes acrylic resin which binds to ultra-light materials during the prosthetic socket fabrication process to create a rigid prosthetic socket. The unit of service for L5629 and L5631 is one per limb.
  • Adjustable Residual Limb Volume Management- L5783 describes a complete mechanical product used as an addition to current lower extremity prosthetic base socket and socket replacement codes. This system is a kit of components (reel, cable, or similar) incorporated into a custom-fabricated socket. The beneficiary can manually adjust their socket volume throughout the day, decrease or increase. The Healthcare Common Procedure Coding System (HCPCS) code may include the lamination kit. The predicate product is the RevoFit manufactured by Click Medical. The unit of service is one per limb.
  • Ischial Containment/Narrow M-L- L5649 describes an addition to an above knee prosthetic socket where the socket design includes containment of the ischial tuberosity and a proximal narrow mediolateral socket dimension to provide mediolateral socket stability during single-limb support. The unit of service is one per limb.
  • Flexible Inner Socket, External Frame- L5643, L5645, and L5651 describe an addition to a prosthetic socket that includes a flexible inner socket with a rigid outer/external frame. The flexible inner socket is made of materials that allow for movement around the residual limb, materials can be elastic, flexible thermoplastic, or silicone-based materials (not all inclusive). The rigid external frame provides stability to the flexible inner socket and a rigid connection to other components. The unit of service for codes L5643, L5645, and L5651 is one per limb.
  • Total Contact- L5637 and L5650 describe an addition to a prosthetic socket where the entire inner surface of the prosthetic socket maintains consistent contact with the entire surface of the residual limb. The unit of service for codes L5637 and L5650 is one per limb.​

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 (e.g., separately, simultaneously with the prosthesis) other than as a replacement shoe for an existing lower limb prosthesis.
ACCESSORIES (E.G., 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.

When the member has the benefit for a lower limb prosthesis, the repair or replacement of a lower limb prosthesis, supplies, or one or more of its components (parts) may be covered and eligible for reimbursement consideration by the Company when all of the requirements for a repair or replacement are met. 
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The repair or replacement of a lower limb prosthesis 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 prosthesis or one or more of it components (parts) due to a change in medical and/or functional status, such that the lower limb prosthesis 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 prosthesis requested.

The Company may determine the reasonable useful lifetime of a specific external prosthetic device based on the manufacturer's recommendation or the US 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 it is generally not less than 5 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 individual 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.
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BILLING REQUIREMENTS

The right (RT) and left (LT) modifiers must be used when reporting prostheses codes. When the same codes for prostheses, sockets, or components for bilateral users 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.

Code L5999 (LOWER EXTREMITY PROSTHESES, NOT OTHERWISE SPECIFIED) is not eligible for separate reimbursement when used to report features or functions that are included within the allowance for base socket or addition codes.

Code  L5999 (LOWER EXTREMITY PROSTHESES, NOT OTHERWISE SPECIFIED) is not eligible for separate reimbursement when used to report features or functions that are ​not specifically described by existing L-codes.​

​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. 

 STANDARD WRITTEN ORDER REQUIREMENTS

Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written 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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)

 The 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 7 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 5 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 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 individuals.

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 Misspelled Wordpr​Misspelled Wordoduct 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

 For members enrolled in New Jersey products, refer to the applicable Orthotic and Prosthetic mandate.​

Description

A lower limb prosthesis is an artificial lower extremity for an individual who has sustained an amputation or has congenital absence or malformation of the lower extremity. 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.
  • Endos​keletal 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 individual, 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 individual'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 individual'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 individual. 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) 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) 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) 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.
ADDITIONAL CONSIDERATIONS FOR PEDIATRICS

Most pediatric prosthetic evaluation and management occurs as the result of trauma or congenital limb deficiency. A lower extremity prosthesis related to a congenital deficiency may be easier to fit than one resulting from trauma because the child with a traumatic amputation may experience boney overgrowth and will have to adjust their body image to the loss of their amputated limb. In addition, throughout their childhood and adolescence, pediatric individuals may utilize prostheses full time, part time, or totally reject prosthetic wear, depending on their developmental and social milestones.

The ability to pull to stand (approximately 9 to 12 months of age) is cited as an indicator for a first fitting for infants with congenital lower limb deficiencies. A knee joint is recommended when the child is able to climb stairs, which occurs around 2 to 3 years of age. Whether congenital or trauma-related, the child's motor, cognitive, and perceptual development should be considered to determine the best type of prosthesis for the child.

Due to growth, the socket of the lower extremity prosthesis should be assessed every 3 to 4 months through adolescence for fit and alignment. A new socket and other prosthetic modifications may be necessary at least once a year for children less than 5 years old, every 2 years for children 5 to 12 years of age, and every 3 years through adolescence to allow for normal growth and development. This depends upon skeletal growth (especially a challenge with pediatric traumatic amputations due to boney overgrowth), as well as general growth because of changes in muscle and body mass.

References

American Academy of Orthotists and Prosthetists. Standards of care. J Prosthet Orthot. 2004;16(3S):6-12.


Centers for Medicare & Medicaid Services (CMS). Federal Register. FINAL RULE: Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding (CBP) proposed amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements; [Federal Register Web site]. Original: 11/08/2019. (Revised: 01/13/2026). Available at: https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/dmepos/downloads/final-rule-master-list-of-dmepos-subject-to-frequent-unnecessary-utilization-2018-03-30.pdf. Accessed April 21, 2026.


Centers for Medicare & Medicaid Services (CMS). Federal Register Vol. 88, No 10. Medicare Program;  Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. [Federal Register Web site]. original 01/17/2023. Available at https://www.govinfo.gov/content/pkg/FR-2023-01-17/pdf/2023-00718.pdf. Accessed April 21, 2026.


Centers for Medicare & Medicaid Services (CMS). Federal Register Vol. 89, No. 93. Medicare Program; Updates to the Master List of Items Potentially Subject to Face-to-Face Encounter and Written Order Prior To Delivery and/or Prior Authorization Requirements; Updates to the Required Face-to-Face and Written Order Prior To Delivery List; and Updates to the Required Prior Authorization List. [Federal Register Web site]. 05/13/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2024-05-13/pdf/2024-10356.pdf. Accessed April 21, 2026.


Centers for Medicare & Medicaid Services (CMS). Required face-to-face encounter and written order prior to delivery list. [CMS Web site]. Effective 04/13/2026. Available at: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf. Accessed April 21, 2026.


Collier T, Nguyen G, Hillebrand M. AAPMR Knowledge NOW: Pediatric acquired upper and lower limb deficiency. [AAPMR website]. Original: 9/20/2014. (Revised 9/23/2021). Available at: https://now.aapmr.org/pediatric-acquired-upper-and-lower-limb-deficiency/. Accessed April 21, 2026.

Cummings DR, Kapp SL. Lower-limb pediatric prosthetics: general considerations and philosophy. J Prosthet Orthot. 1992;4(4) 36-46.

Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). Facts about upper and lower limb reduction defects. [CDC website]. 4/2018. Available at:  https://www.cdc.gov/birth-defects/about/limb-reduction-defects.html?CDC_AAref_Val=https://www.cdc.gov/ncbddd/birthdefects/ul-limbreductiondefects.html. Accessed April 21, 2026.


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 April 21, 2026.


Noridian Article A52481. Orthopedic Footwear-Policy Article. [Noridian Web site]. Original 10/01/2015. (Revised: 11/01/2023). Available at:  https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52481. Accessed April 21, 2026.
 
Noridian Article A52496. Lower limb Prostheses-Policy Article. [Noridian Web site]. Original: 10/01/2015. (Revised: 04/01/2026). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52496. Accessed April 21, 2026.


Noridian. Local Coverage Determination (LCD). L33641: Orthopedic Footwear. [Noridian Web site]. Original: 10/01/2015. (Revised: 01/01/2020). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33641. Accessed April 21, 2026.


Noridian. Local Coverage Determination (LCD). L33787: Lower limb prostheses. [Noridian Web site]. Original: 10/01/2015. (Revised: 0 4/01/2026). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33787 .  Accessed April 21, 2026.


Prosthetic FAQs for the New Amputee. [ACA website]. 01/2021. Available at: https://www.amputee-coalition.org/prosthetics-types-guide/. Accessed April 21, 2026. This site no longer exists.


Smith DG. Congenital limb deficiencies and acquired amputations in childhood. inMotion. 2006;16(1):41-45. Available at: https://www.amputee-coalition.org/resources/amputations-in-childhood/. Accessed April 21, 2026. This site no longer exists.


Weppner, J. DO.  AAPMR Knowledge NOW: Congenital lower limb deficiency. [AAPMR website]. Original:12/2/2013. (Revised 5/23/2024). Available at: https://now.aapmr.org/congenital-lower-limb-deficiency/. Accessed April 21, 2026.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
See Attachment A.
Revenue Code Number(s)
N/A

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

Policy History

Revisions From ​05.00.59s:
06/29/2026

This version of the policy will become effective 06/29/2026.​


The following section has been revised for clarity:


Prosthetic Sockets


The Billing Requirements section has been revised to include:

  • Code L5999 (LOWER EXTREMITY PROSTHESES, NOT OTHERWISE SPECIFIED) must not be used to bill for any features or functions included in the socket or addition codes. Use of L5999 is incorrect coding (unbundling).
  • ​Use of L5999 to describe features or functions not specifically designated by an L-code would be considered incorrect coding (unbundling)​​
​The following section has been added to the Coding Table in Attachment A of this policy:

​Not Eligible for Separate Reimbursement


​The following HCPCS code has been added to the Not Eligible for Separate Reimbursement section of attachment A:

  • L5999 LOWER EXTREMITY PROSTHESES, NOT OTHERWISE SPECIFIE​D​​
The following section has been added to the Coding Table in Attachment A of this policy
Not Eligible for Separate Reimbursement

​The following HCPCS code has been added to the Not Eligible for Separate Reimbursement section of attachment A:

  • L5999 LOWER EXTREMITY PROSTHESES, NOT OTHERWISE SPECIFIE​D​


Revisions From ​05.00.59r:
04/01/2026

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for a HCPCS code update, effective 04/01/2026.

The following HCPCS has been added to attachment A of this policy:

  • L5992 All lower extremity prosthesis, foot shell for modular foot/non-solid ankle cushion heel (sach) replacement only​​

Revisions From ​05.00.59q:
10/01/2025

​This policy has been identified for a HCPCS code update, effective 10/01/2025.

The following HCPCS code has been added to attachment A of this policy:

  • L5657 Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials​
The following HCPCS codes have been​ revised in  attachment A of this policy:

  • L5673 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric, or equal, with or without perforations, with or without breathable material, for use with locking mechanism
  • L5679 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric, or equal, with or without perforations, with or without breathable material, not for use with locking mechanism
  • L5783 Addition to lower extremity, user adjustable, mechanical, residual limb volume management system (with or without lamination kit)​

Revisions From ​05.00.59p:
​04/02/2025
This version of the policy will become effective 04/02/2025.

This policy has been reissued in accordance with the Company's annual review process.

10/01/20​24

This version of the policy will be issued on 11/04/2024 with a retroactive effective date of 10/01/2024.

​

Face-to-face requirement language has been deleted per Centers for Medicare & Medicaid Services (CMS) Final Rule for the following Healthcare Common Procedure Coding System (HCPCS) codes:


  • L5926 Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
  • L5991 Addition to lower extremity prostheses, osseointegrated external prosthetic connector​

Revisions From ​05.00.59o:
08/12/20​24

​This version of the policy will become effective 08/12/2024.

 

Face-to-face requirement language has been added per Centers for Medicare & Medicaid Services (CMS) Final Rule for the following Healthcare Common Procedure Coding System (HCPCS) codes:


  • L5926 Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type
  • L5991 Addition to lower extremity prostheses, osseointegrated external prosthetic connector

Revisions From ​05.00.59n:
04/01/2024
​This policy has been identified for code update, effective 04/01/2024.

The following HCPCS codes have been added to this policy:

  • ​L5783: Addition to lower extremity, user adjustable, mechanical, residual limb volume management system
  • L5841: Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control​​

Revisions From ​05.00.59m:
​01/02/2024
​This policy has been identified for code update, effective 01/02/2024.

The following HCPCS code has been deleted from this policy:
  • ​K1022: Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type​
The following HCPCS code has been added to this policy:
  • ​L5926: Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type​​
The following HCPCS code has been added to this policy with a retroactive effective date of 10/01/2023:
  • L5991: Addition to lower extremity prostheses, osseointegrated external prosthetic connector

Revisions From 05.00.59l:
0​2/27/2023
This version of the policy will become effective 02/27/2023. The intent of this policy remains unchanged; however, the following criteria has been added to this policy for Definitive Prosthesis.​
  • Definitive Prosthesis is considered medically necessary and, therefore covered:
    • ​For an individual who is at a functional mobility level of K3 or above and is receiving an approved microprocessor knee (see Cross-Reference Policy section)​.​

Revisions From ​05.00.59k:
​10/01/2021
​This policy has been identified for code update, effective 10/01/2021.

The following code has been added to this policy:
  • ​K1022: Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type​​

Revisions From 05.00.59j:
04/08/2020This policy has been reissued in accordance with the Company's annual review process.
06/17/2019This version of the policy will become effective 06/17/2019. The intent of this policy remains unchanged; however, the following criteria has been added to this policy for the Repair and Replacement a lower limb prostheses:
  • The repair or replacement of a lower limb prosthesis, supplies, or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when the external prosthetic device itself is covered under the individual's medical benefits and all of the requirements for a repair or replacement are met.
The following medically necessary criteria were revised to include individuals with congenital absence or malformation of the lower extremity:

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 or has congenital absence or malformation of the lower extremity.
For individuals with unilateral lower extremity amputation or unilateral congenital absence or malformation of the lower extremity, only one lower limb prosthesis is considered medically necessary and, therefore, covered.

Revisions From 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.
6/29/2026
6/29/2026
05.00.59
Medical Policy Bulletin
Commercial
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No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.