Lower Extremity Prostheses - DME.MU.107.A

EviCore covers medically necessary lower limb prostheses and specified HCPCS-coded components (with many items restricted to K1–K4 functional levels) and allows replacements/repairs for loss, irreparable wear, or change in medical condition, but excludes devices for K0 patients, cosmetic/ recreational/duplicate/water prostheses, consumables, and certain powered or osseointegration devices deemed experimental. Coverage requires documented functional assessment and K‑level justification showing expected/maintained functional potential, provider credentials, RT/LT modifiers, adherence to coding/unbundling and quantity limits (e.g., two test sockets, two socket inserts, sheaths limits), and specific medical rationale for nonstandard quantities or use of L5999 and for special powered-device criteria (e.g., L5859).

"A user-adjustable heel height feature (HCPCS L5990) is not covered."