Lower Limb Prostheses

Lower limb prostheses are covered when the beneficiary is expected to reach or maintain a defined functional state within a reasonable period and is motivated to ambulate; coverage and component selection are determined by a documented functional (K) level (0–4). Specific component coverage depends on K-level thresholds (e.g., many feet/knees/ankles/hips have minimum K-levels) and advanced technologies (microprocessor systems, powered additions) have additional documentation and functional criteria. Claims without required documentation (SWO/WOPD, clinical functional evaluation, proof of delivery) or that exceed specified limits (e.g., >2 test sockets) or are for explicitly excluded HCPCS codes (e.g., L5969, L5990) will be denied.

"A lower limb prosthesis is covered when the beneficiary is expected to reach or maintain a defined functional state within a reasonable period of time."