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Lower Limb Prostheses
MA05.024l

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.​

MEDICALLY NECESSARY

A lower limb prosthesis is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The individual has undergone an amputation of a 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 a 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 Medicare's Functional Classification Levels (MFCL).

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.
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.
Level 2 Has 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 3 Has 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 4 Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

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.

PROSTHETIC FOOT COMPONENT
A basic lower extremity prosthesis includes a solid ankle cushion heel (SACH) foot. Other types of prosthetic feet are considered for coverage, based on the functional ability and level 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.

A microprocessor-controlled ankle/foot system (L5973), an energy-storing foot (L5976), a dynamic-response foot with a multiaxial ankle (L5979), a flex-foot system (L5980), a flex-walk system or equal (L5981), and a shank-foot system with vertical-loading pylon (L5987) are considered medically necessary and, therefore, covered when one of the following criteria are met:
    • The individual's potential functional ability is at Level 3 or above or
    • The individual's functional level is 2; and​
      • Meets the functional level 2 coverage criteria for a fluid, pneumatic, or electronic/microprocessor control addition for a prosthetic knee; and,
      • A higher-level (i.e., functional level 3) foot is required for the safe and proper use of the prescribed knee system.

​PROSTHETIC ANKLE COMPONENT

An axial rotation unit (L5982, L5984, L5985, 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 for coverage, based on the functional ability and level 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, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5856, L5857, L5858) is considered medically necessary and, therefore, covered when the following criteria are met:
  • The individual's potential functional ability is at Level 3 or above or
  • The individual's functional level is 2 and all of the following criteria are met:
    • The individual has had a clinical evaluation to determine their functional level; and
    • Supporting documentation in the medical record outlines, in the context of the individual's overall medical health, the rationale for selection of a fluid, pneumatic, or electronic/microprocessor-controlled knee (at minimum), how the selected knee will:
      • Improve the beneficiary's functional health outcomes (e.g., fall reduction, injury prevention, lower energy expenditure); and,
      • Help the beneficiary accomplish their activities of daily living (ADLs); and,
    • Lower-level knee systems (e.g., knee systems that exclude use of fluid, pneumatic or microprocessor​) have been considered and ruled out based on the member's specific functional and medical needs.
  • In addition, for coverage of an electronic/microprocessor-controlled knee system (L5856, L5857, or L5858 plus associated components) for individuals whose functional level is 2, all of the following criteria must also be met:
    • The electronic/microprocessor knee is indicated for functional level 2; and,
    • The electronic/microprocessor knee has integrated technology that allows the knee to detect when the user trips or stumbles and can automatically adjust to stabilize the knee unit (e.g., stumble recovery); and,
    • ​The individual is able to make use of a product that requires daily charging; and,
    • ​​​​The individual is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.​
​Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5816, L5818) are considered medically necessary and, therefore, covered for individuals whose potential functional ability is at Level 1 or above.

An addition to a lower extremity prosthesis, an endoskeletal knee-shin system, or a powered and programmable flexion/extension assist control, including any type of motor(s) (L5859), is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The individual has a microprocessor-controlled knee (swing and stance phase type [L5856], including electronic).
  • The individual is at a functional Level 3 only.
  • The individual has a documented morbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs functioning at Level 3 with the use of a microprocessor-controlled knee alone.
  • The individual is able to use a product that requires daily charging.
  • The individual is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.
If the above coverage criteria for the knee component are not met, then L5859 will be considered not medically necessary and, therefore, not covered.

PROSTHETIC HIP COMPONENT
A pneumatic or hydraulic polycentric hip joint (L5961) is considered medically necessary and, therefore, covered for individuals 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 an Immediate Postoperative Prosthesis (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, L5679, 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 and functional need changes, or irreparable wear-and-tear damage due to an individual's excessive weight or to 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. 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.​​

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 medically necessary lower limb prosthesis that meets the 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 Healthcare Common Procedure Coding System (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 are considered not medically necessary and, therefore, not covered.

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 are considered not medically necessary and, therefore, not covered.

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 are considered not medically necessary and, therefore, not covered.

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 are considered not medically necessary and, therefore, not covered.

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 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.

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.

A user-adjustable heel-height feature (L5990) is considered not medically necessary and, therefore, not covered.

EXPERIMENTAL/INVESTIGATIONAL

The microprocessor foot or ankle system addition with power assist, which includes any type motor (L5969), is considered experimental/investigational and, therefore, not covered.

NOT COVERED

A prosthetic donning sleeve (L7600) is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The following items are included in the reimbursement for a prosthesis and are, therefore, not separately reimbursed:
  • Evaluation of the residual limb and gait
  • Fitting of the prosthesis
  • Cost of base component parts and labor contained in HCPCS base codes
  • Repairs due to normal wear or tear within 90 days of delivery
  • Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90 days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the individual's functional abilities.
Foot covers are included in the HCPCS base codes that represent the prosthetic foot component and are, therefore, not separately reimbursable.

​ 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 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.

BILLING REQUIREMENTS
​
An order for each item billed must be signed and dated by the professional provider who is treating the member and kept on file by the supplier. Medical record documentation must include a shipment confirmation or member's receipt of supplies and equipment. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

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 technological 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 in which 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.

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.​

Guidelines

A repair is a restoration of the prosthesis to correct problems due to wear or damage.

An adjustment is any modification to the prosthesis due to a change in the individual's condition or to improve the function of the Misspelled Wordprothesis.​

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, lower limb prostheses are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or not covered are not eligible for coverage or reimbursement by the Company.

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 design of the 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.

References

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: 05/13/2024). 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 May 19, 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 May 19, 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 May 19, 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 

May 19, 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 May 19, 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 May 19, 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&ver=40&keyword=Lower limb prostheses&keywordType=starts&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1  .  Accessed May 19, 2026.


Noridian. Noncovered Items. Last Updated October 25, 2018. Available at: https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed May 19, 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

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.

Coding and Billing Requirements

Policy History

Revisions From ​MA05.024l:
​06/29/2026

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

 

The following section has been revised in accordance with Medicare: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

Revisions From ​MA05.024k:
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 ​MA05.024j:
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 ​MA05.024i:
​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.​​

​04/01/2025

​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 code update, effective 04/01/2025.
​
The following HCPCS code has been added to the medically necessary section of this policy:
  • L5827 Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping

Revisions From ​MA05.024h:
10/012024​

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


The following HCPCS codes have been added to this policy:

  • L5615 Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control

The following policy requirements have been revised:

  • PROSTHETIC FOOT COMPONENT
  • PROSTHETIC KNEE COMPONENT

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 ​MA05.024g:
08/12/2024​

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

 

Face-to-fa​ce 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 ​MA05.024f:
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 ​MA05.024e:
​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 disarti​culation, 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 ​MA05.024d:
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
​02/08/2023This policy has been reviewed and reissued to communicate the Company’s continuing position on Lower Limb Prostheses.​
​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 MA05.024c:
04/08/2020This policy has been reissued in accordance with the Company's annual review process.
04/22/2019This version of the policy will become effective 04/22/2019. The intent of this policy remains unchanged; however, the following weight range criteria for an addition to a lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type of motor(s) (L5859) has been deleted consistent with Noridian's local coverage determination:
  • The individual's weight is between 110 lbs and 275 lbs.
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 prostheses, 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 HCPCS code has been added to Attachment A of this policy:
L5999 Lower extremity prosthesis, not otherwise specified

Revisions From MA05.024b:
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

Revisions From MA05.024a:
06/21/2017This policy was reviewed and reissued in accordance with the Company's Policy Confirmation Review track. The references were updated accordingly. The policy was updated to be consistent with current template wording and format. Source for the policy: BCBSA policy 1.04.05: Microprocessor-Controlled Prostheses for the Lower Limb last reviewed April 2016.
08/17/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on lower limb prostheses.
11/20/2015This version of the policy will become effective 11/20/2015.

This policy was updated to add a policy coverage position for the microprocessor foot or ankle system addition with power assist (L5696) as experimental/investigational.
Revisions From ​​​MA05.024:​​
01/01/2015This is a new policy.

Note: on 12/18/2014 this Policy Notification was updated in accordance with the HCPCS coding update effective 1/1/2015.

The following revisions were made to this policy, in Attachment A.

The following HCPCS narrative has been revised in this policy:

Code: L7367

From: Lithium ion battery, replacement
To: Lithium ion battery, rechargeable, replacement

6/29/2026
6/29/2026
MA05.024
Medical Policy Bulletin
Medicare Advantage
{"7547": {"Id":7547,"MPAttachmentLetter":"A","Title":"HCPCS Level II Codes Number(s) and Narrative(s)","MPPolicyAttachmentInternalSourceId":10653,"PolicyAttachmentPageName":"1473e88d-422d-411d-86bc-8f189b957337"},}
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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.