Lower Limb Prostheses - Medical Clinical Policy Bulletins

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Table Of Contents

Policy

Applicable CPT / HCPCS / ICD-10 Codes

Background

References

Policy

Scope of Policy

This Clinical Policy Bulletin discusses lower limb prostheses.

1. Medical Necessity

   1. Criteria for Lower Limb Prostheses

      Aetna considers an orthosis (orthopedic brace) and/or prosthesis medically necessary when:

      1. Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional qualified by state law; and
      2. The orthosis or prosthesis will significantly enhance or restore physical functions related to mobility activities of daily living (ADLs); and
      3. The participating physician or licensed healthcare professional has determined that the orthosis or prosthesis will enable the member to perform ADLs based on thorough evaluation; and
      4. Service is provided within six months of the prescription date; and
      5. The orthotic or prosthetic services are performed by a licensed and/or certified professional; and
      6. The services are complex enough to warrant being provided by a licensed professional orthotist and/or prosthetist or under their direct supervision as allowed by law; and
      7. The certified professional must be in good standing with the appropriate credentialing body.

   Aetna considers lower limb prostheses medically necessary for performing normal daily activities when the following criteria are met:

   1. Member has the motivation to ambulate; and
   2. Member meets the specific criteria for lower limb prostheses below; and
   3. Member will reach or maintain a functional state within a reasonable time frame.

   A replacement prosthesis is not deemed medically necessary unless the member's medical needs are not met by the existing prosthetic or if it is broken and unrepairable.

   Clinical assessments consider the member's rehabilitation potential based on classification levels described below.

   Levels and Clinical Assessments of Member Rehabilitation Potential:

   Classification Levels

   Level 0: Unable to ambulate or transfer safely, and a prosthesis will not improve their quality of life.

   Level 1: Able to use a prosthesis for transfers or ambulation on level surfaces.

   Level 2: Can traverse low environmental barriers like curbs or stairs.

   Level 3: Ambulates with variable cadence and can navigate most barriers.

   Level 4: Can ambulate beyond basic skills, exhibiting high levels of physical activity.

   The expected functional ability information must be thoroughly documented in the prosthetist's records. A simple code entry is not adequate. For functional levels K3 or higher, a documented evaluation must be submitted by a physical therapist.

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   Background

   A prosthesis or prosthetic device serves to replace missing body parts. A lower limb prosthesis aims to restore functionality in the lower extremity. Prosthetic knees provide support during walking, maintaining flexibility for various activities, whether sitting or kneeling. Lower limb prostheses consist of components that create a seamless connection between the remaining limb and the prosthetic joint through pylons.

   Prosthetic feet have essential functions like providing a stable base, shock absorption, and replicating the foot biomechanics necessary for ambulation.

   Advanced prosthetic designs allow for movements in all directions, facilitating operation on uneven terrain. The solid ankle cushion heel (SACH) contains a rigid core, ideal for basic walking but limited on rough surfaces.

   Conventional prosthetic designs rely on mechanical control, using pneumatic or hydraulic components to adjust based on walking pace and style. Newer microprocessor-controlled types, however, employ sensors to adaptively modify support based on real-time feedback.

   The C-leg, cleared by the FDA, has been recognized as a superior advancement over traditional models, promoting more natural and effective mobility. Despite numerous studies outlining the benefits of such advanced technology, ongoing explorations into optimal performance and patient adaptability are necessary.

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   As we advance into the future of lower limb prostheses, continuous refinements will be vital to meet user demands and functionality needs.