L7364, Twelve volt battery, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without 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
- Upper extremity prosthetic device is medically necessary when: (a) traumatic or surgical amputation or congenital absence; (b) prosthetic replaces all/part of missing limb; (c) prosthetic will help regain/maintain function; (d) device ordered by/under direction of physician; (e) needs evaluated by qualified professional annually; (f) patient willing/able to train; (g) rehabilitation potential with ADL/IADL assessment.
- 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.
9 Active Policies
UHC-POL-upper-extremity-prosthetic-devices, Upper Extremity Prosthetic Devices
AETNA-CPB-0578, Lower Limb Prostheses
DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSIL-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
BCBSMT-DME104.001, Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.