Article Detail - JD DME

Posted February 01, 2013

When providing additions to a lower limb prosthesis, the determination of medical necessity for certain components/additions is based on the beneficiary's potential functional abilities.

Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

• The beneficiary's past history (including prior prosthetic use if applicable); and

• The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and

• The beneficiary's desire to ambulate.

Clinical assessments of beneficiary's rehabilitation potential must be based on the classification levels listed in the Local Coverage Determination (LCD) for Lower Limb Prostheses.

For example:

• An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for beneficiaries whose functional level is 1 or above.

• A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for beneficiaries whose functional level is 2 or above.

• A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) are covered for beneficiaries whose functional level is 3 or above.

Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the physician's or prosthetist's files.

If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary.

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