CG-DME-13 Lower Limb Prosthesis

This policy addresses coverage of lower limb prostheses and related components for individuals with lower-extremity amputations. Coverage is medically necessary when all are documented: a physician prescription, an expectation the member will reach or maintain a defined functional state within a reasonable time, a need for ambulation, and rehabilitation potential supported by Functional Level/K-Level assessment; selection should reflect demonstrated medical need and expected functional level. Not medically necessary if these criteria are not met, for individuals at K0 (no ambulation potential), for prosthetics primarily for leisure/sport, for test (diagnostic) sockets used for immediate post-surgical or early fittings, or for more than two test sockets per prosthesis without additional documented need.

"A lower limb prosthesis is consideredmedically necessarywhenallthe following are met and are documented in the medical record:"