S78.119D — Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- ICD-10-CM diagnosis code(s) documenting the current or past pressure ulcer as listed in the policy's "ICD-10-CM Diagnosis Codes That Support Medical Necessity" section
- Clinical documentation in the medical record verifying presence or history of a pressure ulcer and its location corresponding to the seating contact area
- Comprehensive, written evaluation by a licensed/certified medical professional (PT or OT) that clearly explains why a prefabricated seating system is not sufficient to meet seating and positioning needs.
- Documentation that the member meets all criteria for the applicable prefabricated seat cushion or prefabricated positioning back cushion.
Key Coverage Criteria
- Microprocessor controlled knee prostheses are consideredmedically necessaryfor individuals with transfemoral (above knee) and knee disarticulation amputations whenallof the criteria set forth in (A) and (B) below have been met:Selection criteria:Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;andIndividual has a functional K-Level 3 or above;andThe provider has documented that there is a reasonable likelihood of better mobility [...]
- Selection criteria:Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;andIndividual has a functional K-Level 3 or above;andThe provider has documented that there is a reasonable likelihood of better mobility or stability with the device instead of a mechanical knee prosthesis;andThere is documented need for ambulation in situations where the device will provide benefit (for example, regular need to ascend/descend stairs, traverse u [...]
- Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;and
- Individual has a functional K-Level 3 or above;and
- The provider has documented that there is a reasonable likelihood of better mobility or stability with the device instead of a mechanical knee prosthesis;and
- There is documented need for ambulation in situations where the device will provide benefit (for example, regular need to ascend/descend stairs, traverse uneven surfaces or ambulate for long distances [generally 400 yards or greater cumulatively]);and
2 Active Policies
AMBETTER-CP.MP.99 — Wheelchair Seating
ANTHEM-GL-E002529 — CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis
Related Codes
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