Prosthetic Limb Devices Guideline (0115-GL ... - Physicians Plus

Prosthetic Limb Devices Guideline (0115‐GL‐DEPT‐0022‐HS)
Guideline:
Prior authorization does not guarantee payment. Coverage of services is based on member
eligibility and member’s benefits per the medical certificate of coverage at the time services are
rendered.
Physicians Plus will cover prosthetic models, according to the below guidelines up to the limits
of the Policy when prescribed by a Participating Provider for treatment of an illness or injury.
1. Coverage is limited to the base model that can facilitate/accommodate basic activities of
daily living (ADL) deficiencies caused by the medical condition. Microprocessors are not
covered.
a. The base model prosthetic appliance for replacement of an upper extremity, either
below or above the elbow, is a body‐powered prosthesis with a terminal hook device.
b. Coverage of knee prostheses are based on functional ability. Microprocessors are not
covered.
i. Temporary models will be approved within the first six (6) months of an amputation.
ii. Requests for a permanent prosthesis must be accompanied by medical necessity
documenting adequate healing of the stump per the treating surgeon.
iii. Knee prosthesis exclusions:
L5856, L5857, L5858, L5987, and L5973
2. Coverage is excluded for the sole purpose of work, athletic, or job enhancements.
3. Power enhancements and/or power controls are specifically excluded including but not
limited to: myoelectric devices and microprocessor‐controlled lower limb prostheses (see
list of excluded HCPCS codes below).
4. Repair is covered only when anatomical change or reasonable wear and tear renders the
item nonfunctional and the repair will make the prosthesis usable and is less expensive
than purchasing a new unit.
5. Replacement is covered only when anatomical change or reasonable wear and tear renders
the item nonfunctional, too expensive to repair, or non‐repairable.
6. Replacement and repair will not be covered due to member misuse, abuse, or neglect as
determined by the service provider and/or Physicians Plus; or if the prosthesis has been
lost or stolen.
7. Member can apply the approved amount for the base model toward an upgraded model

via post‐payment reimbursement against receipts.
8. This policy applies to members with Medicare Primary insurance and secondary
commercial insurance; Medicare Supplemental (Select) policy holders are subject to the
criteria as per L27013‐LCD for Lower Limb Prostheses.
Sources of member specific clinical information includes but is not limited to:
• Office and hospital records
• A history of the presenting problem
• Clinical exams
• Diagnostic test results
• Treatment plans and progress notes
• Member psychosocial history
• Consults with the treating provider
• Evaluations from other health care practitioners and providers
• Photos
• Operative and pathology reports
• Rehabilitation evaluations
• Criteria language related to the request
• Certificate language for benefits for the requested service or procedure
• Information regarding the local delivery system
• Patient characteristics and information
• Verbal reports from members or responsible family member
• Letter of medical necessity from provider
The following codes are excluded (in addition to those sited above):
HCPCS
Codes
L6025
L6611
L6646
L6648
L6881
Description
Transcarpal/metacarpal or partial hand disarticulation prosthesis,
external power, self‐suspended, inner socket with removable
forearm section, electrodes and cables, two batteries, charger,
myoelectric control of terminal device
Addition to upper extremity prosthesis, external powered,
additional switch, any type
Upper extremity addition, shoulder joint, multipositional locking,
flexion, adjustable abduction friction control, for use with body
powered or external powered system
Upper extremity addition, shoulder lock mechanism, external
powered actuator
Automatic grasp feature, additin to upper limb electric prosthetic

L6882
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
terminal device
Microprocessor control feature, addition to upper limb prosthetic
terminal device
Wrist disarticulation, external power, self‐suspended inner socket,
removable forearm shell, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
Wrist disarticulation, external power, self‐suspended inner socket,
removable forearm shell, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device
Below elbow, external power, self‐suspended inner socket,
removable forearm shell, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
Below elbow, external power, self‐suspended inner socket,
removable forearm shell, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device
Elbow disarticulation, external power, molded inner socket,
removable humeral shell, outside locking hinges, forearm, Otto
Bock or equal switch, cables, two batteries and one charger, switch
control of terminal device
Elbow disarticulation, external power, molded inner socket,
removable humeral shell, outside locking hinges, forearm, Otto
Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device
Above elbow, external power, molded inner socket, removable
humeral shell, internal locking elbow, forearm, Otto Bock or equal
switch, cables, two batteries and one charger, switch control of
terminal device
Above elbow, external power, molded inner socket, removable
humeral shell, internal locking elbow, forearm, Otto Bock or equal
electrodes, cables, two batteries and one charger, myoelectronic
control of terminal device
Shoulder disarticulation, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
Shoulder disarticulation, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal

L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
device
Interscapular‐thoracic, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device
Interscapular‐thoracic, external power, molded inner socket,
removable shoulder shell, shoulder bulkhead, humeral section,
mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal
device
Electric hand, switch or myoelectric controlled, adult
Electric hand, switch or myoelectric controlled, pediatric
Electric hook, switch or myoelectric controlled, adult
Prehensile actuator, switch controlled
Electric hook, switch or myoelectric controlled, pediatric
Electronic elbow, Hosmer or equal, switch controlled
Electronic elbow, microprocessor sequential control of elbow and
terminal device
Electronic elbow, microprocessor simultaneous control of elbow
and terminal device
Electronic elbow, adolescent, Variety Village or equal, switch
controlled
Electronic elbow, child, Variety Village or equal, switch controlled
Electronic elbow, adolescent, Variety Village or equal,
myoelectronically controlled
Electronic elbow, child, Variety Village or equal, myoelectronically
controlled
Electronic wrist rotator, Otto Bock or equal
Electronic wrist rotator, for Utah arm
Servo control, Steeper or equal
Analogue control, UNB or equal
Proportional control, 6‐12 volt, Liberty, Utah or equal
Guideline Last Update: April 2, 2012