24999
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- Osseointegrated limb prostheses are consideredmedically necessaryfor individuals with transfemoral, transtibial, transhumeral, or forearm amputations whenallof the criteria set forth in (A) and (B) below have been met:
- Selection criteria:Individual is skeletally mature;andHas normal skeletal anatomy;andIs between 18 years old and 70 years old;andDoes not have diabetes;andDoes not have peripheral vascular disease;andDoes not have metabolic bone disease (for example, osteoporosis with T score ≤ -2.5);and
- Individual is skeletally mature;and
- Has normal skeletal anatomy;and
- Is between 18 years old and 70 years old;and
- Does not have diabetes;and
1 Active Policy
ANTHEM-GL-E003563 — CG-OR-PR-10 Osseointegrated Limb Prostheses
Related Codes
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