K1007, Bilateral hip, knee, ankle, foot device, powered, includes pelvic component,
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high 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.
11 Active Policies
HUMANA-ORTHOTICS-MA, Orthotics
ANTHEM-MP-C176719, OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices
AETNA-CPB-0578, Lower Limb Prostheses
DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
BCBSIL-DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
Related Codes
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