Prosthetic Devices - (0536)

Cigna covers prosthetic devices that replace missing or nonfunctional body parts (external facial, ocular, upper and lower extremity terminal devices and necessary accessories) when device‑specific medical necessity criteria are met, but excludes devices/components deemed experimental or not medically necessary (e.g., iris prostheses CPT 66683/C1839, intent‑decoding/pattern‑recognition modules HCPCS L6700, power‑assist/powered lower‑limb features including certain powered ankles/feet and non‑indicated powered knees), K0 lower‑limb prostheses, duplicates, and convenience/recreational items. Coverage requires documentation of functional status (K‑level), failed prior treatments or contraindications, device‑specific clinical criteria (e.g., K3 for most microprocessor/powered lower‑limb components; myoelectric upper‑limb requires cognitive ability and sufficient EMG signal), appropriate coding, and prior authorization when applicable.

"For external facial prosthesis, documentation must show the prosthesis is prescribed to compensate for loss/absence of facial tissue due to disease, injury, surgery, or congenital defect."