L5311
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Other knee systems are consideredmedically necessaryfor members with a functionalLevel 1or above.
- A lower limb prosthesis is consideredmedically necessarywhenallthe following are met and are documented in the medical record:
- The prosthesis is prescribed by physician;and
- The member will reach or maintain a defined functional state within a reasonable period of time;and
- The member needs prosthesis for ambulation;and
- Thememberâs rehabilitation potential is based on Functional Levels (also known as âK-Levelsâ, see Discussion section below for more information);and
1 Active Policy
ANTHEM-CG-DME-13 — CG-DME-13 Lower Limb Prosthesis
Related Codes
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