L6580 — Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden cable control, usmc or equal pylon, no cover, molded to patient model
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit.
- Equipment expected to make a meaningful contribution to treatment of the patient’s illness or injury or to improvement of a malformed body member.
- Coverage only when education regarding use of the device has been provided with demonstrated understanding and a trial of the requested device has been completed with demonstrated ability to use it safely and effectively.
- DME is covered when it is medically necessary and reasonable to treat the member’s condition.
- DME is covered when it provides therapeutic benefit proportional to its expense and is not duplicative of equipment already available to the member.
- Burn garments are considered medically necessary when furnished with associated physical and/or occupational therapy and when the policy's specified criteria are met.
1 Active Policy
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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