Lower Extremity Prostheses - DME.MU.107.A

Covered: lower‑extremity prostheses and listed HCPCS components are covered when the patient is expected to reach/maintain a defined functional state, can ambulate/transfer safely, and meets component‑specific K‑level criteria (K1–K4); devices for K0, cosmetic/backup/recreational/water‑use items, consumables, and specified powered/experimental features are excluded. Key requirements: medical record documentation of expected functional outcome and K‑level, licensed O&P provider, RT/LT modifiers, component‑specific HCPCS coding (use L5999 only with rationale), justification for replacements/repairs and quantity exceptions, and adherence to coding/unbundling and listed quantity limits.

"A lower limb prosthesis is indicated when an individual with a lower extremity amputation meets all the following criteria: the individual is expected to reach or maintain a defined functional stat..."