CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis

This policy addresses microprocessor-controlled lower limb prostheses, specifically microprocessor knees for individuals with transfemoral or knee-disarticulation amputations. Coverage is medically necessary only for microprocessor-controlled knee prostheses when all criteria are met: K3 or higher functional level; adequate cardiovascular reserve and cognitive ability; documented likelihood of improved mobility/stability over a mechanical knee; documented need for ambulation on stairs/uneven terrain or long distances (about 400+ yards); and a complete multidisciplinary assessment with objective documentation by a trained prosthetic clinician. Not covered in all other situations, including for K2 or lower users, for repairs/replacements when criteria are not met, and for microprocessor foot/ankle devices; foot-ankle prostheses with powered propulsion (any motor) are not medically necessary for any indication.

"Microprocessor controlled knee prostheses are consideredmedically necessaryfor individuals with transfemoral (above knee) and knee disarticulation amputations whenallof the criteria set forth in (A..."