Lower Limb Prostheses

Section: Orthotic & Prosthetic Devices
Effective Date: November 01, 2019
Revised Date: September 26, 2019
Last Reviewed: September 26, 2019

Description

Lower limb prosthesis is an artificial device that replaces all or a part of the missing extremity. The application of an appropriate prosthesis is designed to regain or maintain function of the limb, and depends on the functional level of the amputee and the expected functional rehabilitation potential.

The microprocessor-controlled prosthetic knee is designed for lower limb amputees and congenital lack of limb. It is equipped with a sensor that controls the hydraulic that adjusts the swing and stability of the knee based on the position of the foot to permit a more natural walking pattern at varying speeds.

Criteria

Immediate Prostheses

Lower limb prostheses, immediate, may be considered medically necessary for a new or revised amputation when ALL of the following criteria are met:

  • The individual has a lower extremity amputation; and
  • The immediate prosthesis is provided after surgery, while the surgical incision is still healing; and
  • The individual is motivated to ambulate using the prosthesis; and
  • The prosthesis is prescribed by an eligible professional provider (i.e., physician with training and expertise in the functional evaluation of individuals with amputations) and fitted/made by an orthotist or prosthetist.

Lower limb prostheses, immediate, are complete and all-inclusive; therefore, additional components, add-ons, upgrades, test sockets, or substitutions of components, etc., are considered not medically necessary.

Procedure Codes

L5400 L5410 L5420 L5430 L5450 L5460 L5500
L5505

Preparatory Prostheses

Lower limb prostheses, preparatory, may be considered medically necessary for a new or revised amputation when ALL of the following criteria are met:

  • The individual has had an above or below knee amputation; and
  • The preparatory prosthesis is provided to an individual starting a rehabilitation program; and
  • The preparatory prosthesis is provided after the surgical incision has healed; and
  • The individual is motivated to ambulate using the prosthesis; and
  • The preparatory prosthesis is prescribed by an eligible professional provider (i.e., physician with training and expertise in the functional evaluation of individuals with amputations) and fitted/made by an orthotist or prosthetist.

Lower limb prostheses, preparatory, are complete and all-inclusive; therefore, additional components, add-ons, upgrades, adjustments, modifications, or substitutions of components, etc., are considered not medically necessary.

Procedure Codes

L5510 L5520 L5530 L5535 L5540 L5560 L5570
L5580 L5585 L5590 L5595 L5600

Definitive Prostheses

Lower limb prostheses, definitive- initial, may be considered medically necessary when ALL of the following criteria are met:

  • The individual has had an above or below knee amputation; and
  • The definitive prosthesis is provided to an individual who will be participating in a rehabilitation program appropriate for the individual’s expected functional level; and
  • The definitive prosthesis is provided after the surgical incision is stable (healed); and
  • The definitive prosthesis is provided after the residual limb has matured; and
  • The individual is motivated to ambulate using the prosthesis; and
  • The individual is cognitively capable of using the prosthesis to ambulate effectively at the determined functional level [one (1) – four (4)]; and
  • The individual has sufficient neuromuscular control to effectively and appropriately make use of the definitive prosthesis at the determined functional level [one(1) – four (4)]; and
  • The individual has sufficient cardio-pulmonary capacity to effectively use the definitive prosthesis at the determined functional level [one(1) – four (4)]; and
  • The individual has had an in-person medical evaluation with the ordering physician to establish their overall functional capabilities,
    • Note: The ordering physician may delegate this assessment to a licensed/certified medical professional (LCMP) defined as a physical therapist (PT) or occupational therapist (OT), or physician with training and expertise in the functional evaluation of individuals with amputations; and
  • This specialty evaluation must:
    • Evaluate and document the individual’s over-all health status taking into consideration factors related to the amputation and prosthesis use as well the effect of co-morbidities on potential function; and
    • The evaluation must include a complete physical examination including an objective neuromuscular evaluation, cardio-pulmonary capacity evaluation and cognitive evaluation; and
    •  Determine a global activity level as described by the functional level modifiers:
      • Levels zero (0) – four (4) (see link to Additional Information); and
      • The individual has had an in-person evaluation by the prosthetist to evaluate prosthetic needs consistent with the overall functional capabilities identified by the medical examination; and
      • The individual is able to ambulate using the device at or above the identified functional level.

Procedure Codes

L5050 L5060 L5100 L5105 L5150 L5160 L5200
L5210 L5220 L5230 L5250 L5270 L5280 L5301
L5312 L5321 L5331 L5341

Sockets and Socket Inserts

One (1) socket per individual definitive prosthesis may be considered medically necessary when the prosthesis meets above criteria.

Two (2) test (diagnostic) sockets for an individual definitive prosthesis may be considered medically necessary when the prosthesis meets above criteria.

No more than two (2) of the same socket inserts per individual prosthesis at the same time may be considered medically necessary.

One (1) custom fabricated socket insert may be considered medically necessary when the prosthesis meets the above criteria and the ALL of the following:

  • Non-custom socket inserts are unable to provide an adequate interface between the residual limb and socket; and
  • A different type of non-custom insert will not compensate for the irregular contours of the limb.

Socket replacements for a definitive prosthesis may be considered medically necessary when the prosthesis meets the above criteria, and EITHER of the following:

  • There are changes in the residual limb that cannot be accommodated though the use of socket inserts and/or liners and/or stump stockings, and/or modifications to the existing socket; or
  • When the existing socket is irreparable due to damage or wear.

Procedure Codes

L5618 L5620 L5622 L5624 L5626 L5628 L5630
L5632 L5634 L5636 L5638 L5639 L5640 L5642
L5643 L5644 L5645 L5646 L5647 L5648 L5649
L5650 L5651 L5652 L5653 L5654 L5655 L5656
L5658 L5661 L5665 L5673 L5679 L5681 L5683
L5700 L5701 L5702 L5703

Suspension Systems

Mechanical

Mechanical suspension systems including, belts, sleeves, straps, socket design features, and pin-locking mechanisms may be considered medically necessary when the prosthesis meets the above criteria, and the individual’s functional level is one (1) – four (4).

Suction

Passive suction systems may be considered medically necessary when the prosthesis meets above criteria, and the individual’s functional level is one (1) – four (4).

Vacuum Suspension System

Vacuum suspension systems (e.g., vacuum-assisted socket system [VASS™]) may be considered medically necessary to control residual limb volume when there is contraindication to or failure of other socket-suspension systems (e.g., mechanical, passive suction) to adequately secure the limb to the prosthesis; and the individual’s functional level is three (3) – four (4).

Procedure Codes

L5647 L5652 L5666 L5670 L5671 L5672 L5781
L5782 L7700

Feet and Ankles

One (1) foot/ankle may be considered medically necessary when a definitive prosthesis meets the above criteria, and the foot/ankle is appropriate for the individual’s functional level [one (1) – four (4)] as indicated below:

  • An external-keel solid ankle cushion heel (SACH) foot or single-axis ankle/foot may be considered medically necessary for individuals whose functional level is one (1) or above.
  • A flexible-keel foot or multi-axial ankle/foot may be considered medically necessary for individuals whose functional level is two (2) or above.
  • An energy-storing foot, dynamic response with multi-axial ankle, flex-foot system, flex-walk system or equal, or shank system with vertical loading pylon may be considered medically necessary for individuals whose functional level is three (3) or above.
  • An axial rotation unit may be considered medically necessary for individuals whose functional level is two (2) or above.
  • A partial foot prosthesis may be considered medically necessary for individuals whose functional level is one (1) or above.

Procedure Codes

L5000 L5010 L5020 L5970 L5972 L5974 L5976
L5978 L5979 L5980 L5981 L5982 L5984 L5986
L5987

Knees

Prosthetic knees may be considered medically necessary, when a definitive prosthesis meets the above criteria, and the type is based upon the functional needs of the individual as indicated below:

  • A fluid, pneumatic or electronic knee may be considered medically necessary for individuals whose functional level is three (3) or above.
  • A single axis constant friction knee and other basic knee systems may be considered medically necessary for individuals whose functional level is one (1) or above.

Quick change self-aligning units are considered not medically necessary.

Procedure Codes

L5610 L5611 L5613 L5614 L5616 L5710 L5711
L5712 L5714 L5716 L5617 L5718 L5722 L5724
L5726 L5728 L5780 L5810 L5811 L5812 L5814
L5816 L5818 L5822 L5824 L5826 L5830 L5840

Hips

A pneumatic or hydraulic polycentric hip joint may be considered medically necessary when a definitive prosthesis meets the above criteria, and for individuals whose functional level is three (3) or above.

Procedure Codes

L5961

The following are considered not medically necessary:

  • Lower limb prosthesis is considered not medically necessary when the criteria above have not been met.
  • Lower limb prosthesis is considered not medically necessary for functional level zero (0).
  • All parts of a prosthesis are considered not medically necessary when any related part is considered not medically necessary.
  • Duplication or upgrade of a functional prosthesis is considered not medically necessary.
  • Additions/components that are not required for the effective use of the device, or do not serve a functional purpose are considered not medically necessary.
  • Additions provided for cosmetic reasons are considered not medically necessary.
  • Prosthetic devices or additions/components not required for participation in normal activities of daily living, including those that are chiefly for convenience, for participation in recreational activities, or that otherwise exceed the medical needs of the amputee (e.g., back-up prosthetic devices, waterproof leg prosthesis [e.g., Water Leg, used for showering, swimming] are considered not medically necessary.
  • Prosthetic donning sleeve is considered not medically necessary.
  • Protective outer surface covering systems are considered not medically necessary.

Procedure Codes

L5962 L5964 L5966 L5999 L7600

Additions/Accessories

Additions/Accessories may be considered medically necessary when a definitive prosthesis meets the above criteria, and supporting documentation indicates that they aid in, or are essential to, the effective use of the artificial limb, and are appropriate for the individual’s functional level [one (1) – four (4)].

Procedures Codes

L5610 L5611 L5613 L5614 L5616 L5617 L5618
L5620 L5622 L5624 L5626 L5628 L5629 L5630
L5631 L5632 L5634 L5636 L5637 L5638 L5639
L5640 L5642 L5643 L5644 L5645 L5646 L5647
L5648 L5649 L5650 L5651 L5652 L5653 L5654
L5655 L5656 L5658 L5661 L5665 L5666 L5668
L5670 L5671 L5672 L5673 L5676 L5677 L5678
L5679 L5680 L5681 L5682 L5683 L5684 L5685
L5686 L5688 L5690 L5692 L5694 L5695 L5696
L5697 L5698 L5699 L5710 L5711 L5712 L5714
L5716 L5718 L5722 L5724 L5726 L5728 L5780
L5781 L5782 L5785 L5790 L5795 L5810 L5811
L5812 L5814 L5816 L5818 L5822 L5824 L5826
L5828 L5830 L5840 L5845 L5848 L5850 L5855
L5910 L5920 L5925 L5930 L5940 L5950 L5960
L5961 L5962 L5964 L5966 L5968 L5970 L5971
L5972 L5974 L5975 L5976 L5978 L5979 L5980
L5981 L5982 L5984 L5985 L5986 L5987 L5988
L5990 L5999 L8400 L8410 L8417 L8420 L8430
L8440 L8460 L8470 L8480

Repairs/Replacements

Lower limb prostheses replacement during the reasonable useful lifetime (usually based on the manufacturer’s recommendation or FDA-approved labeling) may be considered medically necessary when supporting documentation indicates that the item is lost or irreparably damaged (i.e., fire, flood, etc.).

Lower limb prostheses replacement after the reasonable useful lifetime (usually based on the manufacturer’s recommendation or FDA-approved labeling) may be considered medically necessary for at least ONE of the following when supporting documentation indicates:

  • There is a change in the physiological condition of the individual, and the prosthesis is considered medically necessary; or
  • There is irreparable wear of the device or a part of the device, and the prosthesis is considered medically necessary; or
  • The condition of the device, or part of the device, requires repairs and the cost of such repairs would be greater than 60% of the cost of a replacement device or the part being replaced, and the prosthesis is considered medically necessary.

Lower limb prostheses repairs may be considered medically necessary for EITHER of the following when supporting documentation indicates they are:

  • Required to make the prosthesis functional; or
  • In keeping with the manufacturer’s maintenance recommendations; or
  • Adjustments are required due to wear and tear.

Replacements or repairs not meeting the above criteria are considered non-covered.

Procedures Codes

L5700 L5701 L5702 L5703 L5704 L5705 L5706
L5707 L7510 L7520

Pediatric Lower Limb Prostheses

Pediatric lower limb prostheses may be considered medically necessary for congenital and acquired pediatric limb deficiencies.

Considerations for pediatric lower limb prostheses include:

  • Infants who are born with a missing or partial limb, or children who lose a limb through injury or amputation, should be evaluated by a prosthetist as soon as possible.
  • It is appropriate for infants and very young children to be fit with a passive prosthesis right away so that the prosthetic limb is incorporated into their developing body image.
  • A child is eligible for prosthetics when they are able to stand on their own (approximately 9-12 months of age).
  • Components must be evaluated for age-appropriateness, considering comfort, weight, durability, and function.
  • A new socket and other prosthetic modifications are required at least once a year for children between the ages of birth to 18 years to allow for normal growth and development.
  • Follow-up with a multidisciplinary approach is recommended.

Procedure Codes

L5700 L5701 L5702 L5703 L5704 L5705 L5706
L5707 L7510 L7520

Microprocessor-Controlled Lower Limb Prosthesis

Microprocessor-controlled knee may be considered medically necessary when the following criteria are met:

  • Individual’s functional level is three (3) or above, as indicated by modifier K3 or K4; and
  • There is a demonstrated need for long-distance ambulation at variable rates (use of the limb in the home or for basic community ambulation is not sufficient to justify provision of the computerized limb over standard limb applications); or
  • There is a demonstrated patient need for regular ambulation on uneven terrain or for regular use on stairs (use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application); and
  • Physical ability includes adequate cardiovascular and pulmonary reserve, for ambulation at faster than normal walking speed; and
  • Individual demonstrates adequate cognitive ability to master use and care requirements for the technology; and
  • The patient’s medical record must provide clear documentation of the patient’s history, current condition, and expected functional ability to support the need for the technologic or design feature of the microprocessor-controlled knee. (This information must be retained in the physician’s or prosthetist’s files and be available upon request.)

Microprocessor-controlled knee is considered not medically necessary in individuals who do not meet the above criteria.

Procedure Codes

L5828 L5845 L5848 L5856 L5857 L5858 L5859
L5920 L5930 L5950 L5999

Microprocessor-controlled ankle/foot prosthesis may be considered medically necessary when the individual’s functional level is three (3) or above, as indicated by modifier K3 or K4.

Microprocessor-controlled ankle/foot prosthesis is considered not medically necessary in individuals who do not meet the above criteria.

Procedure Codes

L5973 L5976 L5979 L5980 L5981 L5987

Powered and Programmable Flexion/Extension Assist-Control Prosthetic Knees

Powered and programmable endoskeletal knee-shin system with flexion-extension assist (addition to lower extremity) may be considered medically necessary when ALL of the following criteria are met:

  • The individual has a microprocessor (swing and stance phase type) controlled (electronic) knee; and
  • Individual’s functional level is three (3), as indicated by modifier K3 (the device is not intended for high impact activity, sports, excessive loading or heavy duty use); and
  • Weight is between 110 lbs and 275 lbs; and
  • Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone; and
  • Is able to make use of a product that requires daily charging; and
  • Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

Powered endoskeletal knee-shin system with flexion-extension assist is considered not medically necessary in individuals who do not meet the above criteria.

Procedure Codes

L5856 L5859

Power-Assist Ankle-Foot Prosthetic Systems

Powered ankle or foot prostheses are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

L5969

Additional Information

Functional Level Classification

An in-person, comprehensive medical assessment to determine the functional capabilities of the member must be performed by a licensed/certified medical professional with expertise in the treatment of amputees prior to the provision of any prosthesis.

The member’s functional level is based on their overall health status, the objective results of the medical assessment and their documented performance using their immediately previous prosthesis (either preparatory or definitive).

Assessment of the member’s functional capabilities must be based on the following classification levels:

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 ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
Level 3 Has the ability or potential for ambulation with 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.

 

When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes L5610-L5616, L5710-L5780, L5810-L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5920, L5930, L5950, L5961, L5970-L5987) components must be submitted with modifiers K0 – K4, indicating the beneficiary’s functional level.

Diagnosis Codes

Q72.811 Q72.812 Q72.813 Q72.819 Q72.891 Q72.892 Q72.893
Q72.899 S88.011A S88.011D S88.011S S88.012A S88.012D S88.012S
S88.019A S88.019D S88.019S S88.021A S88.021D S88.021S S88.022A
S88.022D S88.022S S88.029A S88.029D S88.029S S88.111A S88.111D
S88.111S S88.112A S88.112D S88.112S S88.119A S88.119D S88.119S
S88.121A S88.121D S88.121S S88.122A S88.122D S88.122S S88.129A
S88.129D S88.129S S88.911A S88.911D S88.911S S88.912A S88.912D
S88.912S S88.919A S88.919D S88.919S S88.921A S88.921D S88.921S
S88.922A S88.922D S88.922S S88.929A S88.929D S88.929S S98.011A
S98.011D S98.011S S98.012A S98.012D S98.012S S98.019A S98.019D
S98.019S S98.021A S98.021D S98.021S S98.022A S98.022D S98.022S
S98.029A S98.029D S98.029S S98.111A S98.111D S98.111S S98.112A
S98.112D S98.112S S98.119A S98.119D S98.119S S98.121A S98.121D
S98.121S S98.122A S98.122D S98.122S S98.129A S98.129D S98.129S
S98.131A S98.131D S98.131S S98.132A S98.132D S98.132S S98.139A
S98.139D S98.139S S98.141A S98.141D S98.141S S98.142A S98.142D
S98.142S S98.149A S98.149D S98.149S S98.211A S98.211D S98.211S
S98.212A S98.212D S98.212S S98.219A S98.219D S98.219S S98.221A
S98.221D S98.221S S98.222A S98.222D S98.222S S98.229A S98.229D
S98.229S S98.311A S98.311D S98.311S S98.312A S98.312D S98.312S
S98.319A S98.319D S98.319S S98.321A S98.321D S98.321S S98.322A
S98.322D S98.322S S98.329A S98.329D S98.329S S98.911A S98.911D
S98.911S S98.912A S98.912D S98.912S S98.919A S98.919D S98.919S
S98.921A S98.921D S98.921S S98.922A S98.922D S98.922S S98.929A
S98.929D S98.929S Z89.9 Z89.411 Z89.412 Z89.419 Z89.421
Z89.422 Z89.429 Z89.431 Z89.432 Z89.439 Z89.441 Z89.442
Z89.449 Z89.511 Z89.512 Z89.519 Z89.521 Z89.522 Z89.529
Z89.611 Z89.612 Z89.619 Z89.621 Z89.622 Z89.629

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