L5636, Addition to lower extremity, symes type, medial opening socket
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document the beneficiary’s current functional and physical capabilities and the expected functional potential, and must explain differences between current and expected functional states if present.
- A clinical evaluation to determine the beneficiary’s functional level must be performed and documented in the medical record.
- For fluid/pneumatic/electronic knee coverage for functional level 2, the medical record must document the rationale that the selected knee will improve functional outcomes (e.g., fall reduction), help accomplish ADLs, and that lower-level knee systems were considered and ruled out.
- For electronic/microprocessor knee coverage at functional level 2, documentation must show the device is indicated for K2, includes stumble-recovery technology, the beneficiary can perform daily charging, and the beneficiary can understand/respond to error alerts.
Key Coverage Criteria
- A lower limb prosthesis is covered when the beneficiary is motivated to ambulate.
- A lower limb prosthesis is covered when the beneficiary is expected to reach or maintain a defined functional state within a reasonable period of time.
- Coverage and component selection are based on a documented functional level (K-level 0–4) determined by the treating practitioner and prosthetist considering past prosthetic use, residual limb status, comorbidities, and the beneficiary’s desire to ambulate.
- Foot components L5970 or L5974 are covered for beneficiaries with functional level >=1.
- Flexible-keel foot L5972 or multiaxial ankle/foot L5978 are covered for beneficiaries with functional level >=2.
- Microprocessor-controlled ankle/foot (L5973), energy storing (L5976), dynamic response multi-axial (L5979), flex foot systems (L5980,L5981), or shank-foot with vertical loading pylon (L5987) are covered when the beneficiary is functional level >=3, or when functional level =2 and the beneficiary meets the level-2 knee coverage criteria and a higher-level foot is required for safe use of the prescribed knee.
9 Active Policies
ANTHEM-CG-DME-13, CG-DME-13 Lower Limb Prosthesis
L33787, Lower Limb Prostheses
UHC-POL-lower-extremity-prosthetics, Lower Extremity Prosthetics
BCBSIL-DME104.012, Lower-Limb Prosthetics, Including Microprocessor-Controlled Prosthetics
BCBSMT-DME104.012, Lower-Limb Prosthetics, Including Microprocessor-Controlled Prosthetics
Related Codes
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