ankle-cushion heel (SACH) foot is considered medically necessary for persons
whose functional level is 1* or above.
external keel SACH foot or single axis ankle/foot is considered medically
necessary for persons whose functional level is 1* or above.
flexible-keel foot or multi-axial ankle/foot is considered medically necessary
for persons whose functional level is 2* or above.
foot system, energy storing foot, multi-axial ankle/foot, dynamic response foot
with multi-axial ankle, shank foot system with vertical-loaded pylon or
flex-walk system or equal is considered medically necessary for persons whose
functional level is 3* or above.
user-adjustable heel height feature is considered not medically necessary.
Foot covers are included in the reimbursement for a prosthetic foot component
and are not separately payable.
or pneumatic knee is considered medically necessary for persons whose functional
level is 3* or above.
axis constant friction knee and other basic knee systems are considered
medically necessary for persons whose functional level is 1* or above.
A high-activity knee control frame is considered medically necessary for members
whose function level is 4*.
rotation unit is considered medically necessary for persons whose functional
level is 2* or above.
pneumatic or hydraulic polycentric hip joint is considered medically
necessary for members whose functional level is 3* or above.
(diagnostic) sockets for immediate post-surgical or early-fitted prostheses are
considered not medically necessary.
(diagnostic) sockets for an individual prosthetic are considered medically
necessary. Additional documentation of medical necessity is required for more
than 2 test sockets.
than 2 of the same socket inserts per individual prosthesis at the same time are
considered medically necessary.
replacements are considered medically necessary if there is adequate
documentation of functional and/or physiological need, including 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
very active amputees.
stockings and harnesses (including replacements) are considered medically
necessary when they are essential to the effective use of the artificial limb.
sheaths/socks, including a gel cushion layer (prosthetic gel stockings; 6 in 6
months) are considered medically necessary.
seals/gaskets, for use with prosthetic socket insert, are considered medically
prosthetic donning sleeve is considered not medically necessary.
Microprocessor-Controlled Lower Limb Prostheses:
considers microprocessor-controlled leg prostheses (e.g., Otto Bock C-Leg;
Otto-Bock Genium Bionic Prosthetic System (Otto Bock HealthCare, Minneapolis,
MN), Intelligent Prosthesis (Endoliete North America, Centerville, OH), and
Ossur Rheo Knee (Ossur-Flexfoot, Aliso Viejo, CA)) medically necessary in
otherwise healthy, active community ambulating adults (18 years of age or older)
(functional level 3* or above) with a knee disarticulation amputation or a
trans-femoral amputation from a non-vascular cause (usually trauma or tumor) for
whom this prosthesis can be fitted and programmed by a qualified prosthetist
trained to do so.
to lower extremity prosthesis, Endoskeletal knee-shin system, powered and
programmable flexion/extension assist control includes any type of
motor(s) is only considered medically necessary when the member meets all of the
Has a microprocessor (swing and stance phase type) controlled
(electronic) knee; and
K3 functional level only; and
Weight greater than 110 lbs. and less than 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.
exception of items described by specific HCPCS codes, there should be no
separate billing and there is no separate payment for a component or feature of
a microprocessor-controlled knee, including but not limited to real time gait
analysis, continuous gait assessment, or electronically controlled static stance
considers microprocessor-controlled leg prostheses (e.g., Otto Bock C-Leg,
Otto-Bock Genium Bionic Prosthetic System, Intelligent Prosthesis, and Ossur
Rheo Knee) experimental and investigational for gait management in spinal cord
injury because of insufficient evidence in the peer-reviewed literature.
considers a prosthetic shoe medically necessary for a partial foot amputation
when the prosthetic shoe is an integral part of a covered basic lower limb
considers microprocessor-controlled ankle-foot prostheses (e.g., PowerFoot BiOM,
iWalk, Bedford, MA; Proprio Foot, Ossur, and Aliso Viejo, CA) experimental and
investigational because there is inadequate evidence of their effectiveness.
considers the Ossur Symbiotic Leg experimental and investigational because its
clinical value has not been established.
Clinical assessments of a member’s rehabilitation potential should be based on
the functional classification levels listed in the table below.
Does not have the ability or potential to ambulate or transfer safely
with or without assistance and prosthesis does not enhance their quality
of life or mobility.
the ability or potential to use prosthesis for transfers or ambulation
on level surfaces at fixed cadence. Typical of the limited and
unlimited household ambulatory.
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 ambulatory.
the ability or potential for ambulation with variable cadence. Typical
of the community ambulatory who has the ability to traverse most
environmental barriers and may have vocational, therapeutic, or exercise
activity that demands prosthetic utilization beyond simple locomotion.
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