L7510, Repair of prosthetic device, repair or replace minor parts
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Physician certification is required for coverage documenting that the component is ineffective for ADLs, that a medical-condition change necessitates a different component, or that the component reached reasonable useful life.
- For repairs, include original purchase date of the item repaired, the reason for repair/replacement, identification of the item and parts repaired, functionality status, and the manufacturer invoice cost.
- When billing replacements include original purchase date, last replacement date of the item billed, and reason for replacement.
- For exceptions to battery or other limits, submit a narrative in item #19 of the electronic 5010 claim form or an attachment for paper claims.
Key Coverage Criteria
- Replacement of an existing cochlear implant external component is covered when a physician certifies the existing component is ineffective to the point of interfering with activities of daily living.
- Replacement is covered when a change in the patient's medical condition necessitates a different type of external cochlear implant component as certified by a physician.
- Replacement is covered when the existing external component has reached its reasonable useful life; the reasonable useful life of a sound processor is not less than 5 years.
- 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.
10 Active Policies
HUMANA-PROSTHETICS-KY-MEDICAID, Prosthetics
ANTHEM-GL-C169421, CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
ANTHEM-CG-DME-13, CG-DME-13 Lower Limb Prosthesis
ANTHEM-GL-E002529, CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis
A53708, Billing and Coding: External Components for Cochlear Implants
Related Codes
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