K1007 — Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Product information (manufacturer, part number or part name) for prosthetic components must be recorded in the medical records.
- For K3 or above functional levels, a documented evaluation from a physical therapist establishing the functional level and activities is required.
- There must be documentation of the member’s history and current condition that supports the designation of the functional level by the prosthetist and physical therapist.
- Functional ability (K-level) information must be clearly documented and retained in the prosthetist's records; a K modifier alone is insufficient.
Key Coverage Criteria
- Orthosis and/or prosthesis is medically necessary when: care is prescribed by a physician, nurse practitioner, podiatrist or other health professional qualified to prescribe orthotics/prosthetics under State law; the orthosis/prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADLs); the member’s participating physician or licensed health care practitioner has determined the orthosis/prosthesis will allow the member to p [...]
- Lower limb prosthesis is medically necessary when: member is motivated to ambulate; member meets the specific criteria for lower limb prostheses set forth in the policy; and member will reach or maintain a defined functional state within a reasonable period of time.
- Prostheses are considered medically necessary only for functional classification levels K1 and above for certain components and higher K-levels for more advanced components (see device-specific indications below).
- Foot prostheses: SACH foot is medically necessary for persons whose functional level is K1 or above.
- Foot prostheses: External keel SACH foot or single axis ankle/foot is medically necessary for persons whose functional level is K1 or above.
- Foot prostheses: Flexible-keel foot or multi-axial ankle/foot is medically necessary for persons whose functional level is K2 or above.
9 Active Policies
HUMANA-ORTHOTICS-MA — Orthotics - Medicare Advantage
AETNA-CPB-0578 — Lower Limb Prostheses
ANTHEM-MP-C176719 — OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
BCBSIL-DME103.008 — Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
BCBSMT-DME103.008 — Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
Related Codes
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