Q73.8 — Other reduction defects of unspecified limb(s)
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The certified professional orthotist or prosthetist must be in good standing with one or more of the following: American Board for Certification (ABC); or Board of Certification/Accreditation (BOC); or Licensed by the state in which services are provided (where legally required) (document proof of ABC/BOC standing or state licensure).
- For vacuum systems, documentation must support that the medical necessity criteria for a prosthetic limb are met plus documentation of one or more of the specific criteria: excessive pistoning that cannot be resolved by adjustments in the current suspension system; excessive residual limb hyperemia from prior socket use; excessive skin hyperhidrosis from prior socket use; or multiple falls in below-knee (trans-tibial) amputees (document attempts to resolve pistoning if relevant, history of falls, and clinical findings of hyperemia or hyperhidrosis).
- Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law (document prescriber qualifications).
Key Coverage Criteria
- Aetna considers an orthosis (orthopedic brace) and/or prosthesis medically necessary when: Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law; and The orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's); and The member’s participating physician or licensed health care practition [...]
- Multiple falls in below-knee amputees (trans-tibial amputation).
- HCPCS codes L5781 (addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system) and L5782 (heavy duty) are covered when the applicable selection/medical necessity criteria are met.
- ICD-10 diagnosis codes Q72.00 – Q72.93 (reduction defects of lower limb), S98.011+ – S98.929+ (traumatic amputation of ankle and foot), and Z89.411 – Z89.9 (acquired absence of lower limb) are listed as covered diagnoses when the selection criteria are met.
- Aetna considers the eVAC, the Harmony Vacuum Management System (Vacuum Assisted Socket System (VASS)), and the LimbLogic VS Prosthetic Vacuum Suspension System, specialized vacuum pump residual limb volume management and moisture evacuation systems medically necessary for use with lower limb prostheses when the medical necessity criteria for a prosthetic limb are met plus any of the following criteria are met:
- Excessive pistoning of the socket to residual limb interface that cannot be resolved by adjustments in the current suspension system;
1 Active Policy
AETNA-CPB-0630 — Prosthetic Limb Vacuum Systems
Related Codes
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