Medical policy: Lower Limb Prostheses

Policy number: MP 6.042

Effective date: 4/1/2026

Policy

Preparatory prostheses

Preparatory lower limb prostheses may be considered medically necessary for a new or revised amputation when ALL of the following criteria are met:

• The preparatory prosthesis is provided after the surgical incision has healed; and
• The preparatory prosthesis is prescribed by an eligible professional provider (i.e., physician with training and expertise in the functional evaluation of individuals with amputations) and fitted/made by an orthotist or prosthetist.

L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600

Preparatory lower limb prostheses are complete and all-inclusive; consequently, further components, add-ons, upgrades, adjustments, modifications, or substitutions of components, etc., are considered not medically necessary.

Definitive prostheses

Definitive initial lower limb prostheses may be considered medically necessary when ALL of the following criteria are met:

• The definitive prosthesis is provided to an individual whose surgical incision is stable (healed) and will be participating in a rehabilitation program appropriate for the individual’s expected functional level is one (1) to four (4); and
• The individual has had an in-person medical evaluation with the ordering physician to establish their overall functional capabilities.

L5050, L5060, L5100, L5105, L5150, L5160, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341

All other uses of definitive prostheses not described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Microprocessor system

A microprocessor-controlled knee may be considered medically necessary in amputees who meet the following requirements:

• There is a demonstrated need for long distance ambulation at variable rates (use of the limb in the home or for basic community ambulation is not sufficient to justify provision of the computerized limb over standard limb applications) OR demonstrated patient need for regular ambulation on uneven terrain or for regular use on stairs (use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application); and
• The physical and cognitive ability, as well as including adequate cardiovascular and pulmonary reserve, for ambulation at faster than normal walking speed; and
• Individual’s functional level is three (3) or above; and
• The patient’s medical record must provide clear documentation of the patient’s history, current condition, and expected functional ability to support the need for the technologic or design feature of the microprocessor-controlled knee (This information must be retained in the physician’s or prosthetist’s files and be available upon request).

L2006, L5828, L5845, L5848, L5856, L5857, L5858, L5859, L5920, L5930, L5950, L5976, L5979, L5980, L5981, L5987

A microprocessor-controlled knee which does not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Feet and ankles

One (1) foot/ankle prosthetic may be considered medically necessary when a definitive prosthesis meets the above criteria, and the foot/ankle is appropriate for the individual’s functional level as indicated below:

• A partial foot prosthesis may be considered medically necessary for individuals whose functional level is one (1) or above.

L5000, L5010, L5020

• An external-keel solid ankle cushion heel (SACH) foot or single-axis ankle/foot may be considered medically necessary for individuals whose functional level is one (1) or above.

L5970, L5974

• A flexible-keel foot or multi-axial ankle/foot may be considered medically necessary for individuals whose functional level is two (2) or above.

L5972, L5978, L5982, L5984, L5986

• An energy-storing foot, dynamic response with multi-axial ankle, flex-foot system, flex-walk system or equal, or shark system with vertical loading pylon may be considered medically necessary for individuals whose functional level is three (3) or above. (Also, part of a microprocessor-controlled prosthesis)

L5976

A foot and ankle prosthesis which does not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Power-assist ankle-foot prosthetic systems

Powered ankle or foot prostheses are considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

L2221, L5969, L5973

Knees

Prosthetic knees may be considered medically necessary when a definitive prosthesis meets the above criteria, and the type is based upon the functional needs of the individual as indicated below:

• A single axis constant friction knee and other basic knee systems may be considered medically necessary for individuals whose functional level is one (1) or above.

L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5816, L5818

• A fluid, pneumatic or electronic knee may be considered medically necessary for individuals whose functional level is three (3) or above.

L5610, L5613, L5614, L5814, L5822, L5824, L5826, L5830, L5840

A knee prosthetic which does not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Powered and programmable flexion/extension assist-control prosthetic knees

Powered and programmable endoskeletal knee-shin system with flexion-extension assist (addition to lower extremity) may be considered medically necessary when ALL of the following criteria are met (Also part of a microprocessor-controlled prosthesis):

• The individual has a microprocessor (swing and stance phase type) controlled (electronic) knee; and
• Individual’s functional level is three (3), as indicated by modifier K3 (the device is not intended for high impact activity, sports, excessive loading or heavy-duty use); and
• Weight is between 110 lbs and 275 lbs; and
• Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone; and
• Is able to make use of a product that requires daily charging; and
• Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

L5827, L5841, L5856, L5859

A powered and programmable endoskeletal knee-shin system with flexion-extension assist which does not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Hips

A pneumatic or hydraulic polycentric hip joint may be considered medically necessary when a definitive prosthesis meets the above criteria, and for individuals whose functional level is three (3) or above.

L5961

A prosthetic hip is considered not medically necessary in individuals who do not meet these criteria as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Sockets and socket inserts

One (1) socket per individual definitive prosthesis may be considered medically necessary when the prosthesis meets above criteria.

Two (2) test (diagnostic) sockets for an individual definitive prosthesis may be considered medically necessary when the prosthesis meets above criteria.

More than two (2) of the same socket inserts per individual prosthesis at the same time is considered not medically necessary.

One (1) custom fabricated socket insert may be considered medically necessary when the prosthesis meets the above criteria and ALL of the following:

• Non-custom socket inserts are unable to provide an adequate interface between the residual limb and socket; and
• A different type of non-custom insert will not compensate for the irregular contours of the limb.

Socket replacements are medically necessary if there is adequate documentation of functional and/or physiological need. Some situations include but are not limited to changes in the residual limb, functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very active amputees.

L5200, L5321, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5648, L5649, L5650, L5651, L5653, L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5668, L5673, L5679, L5681, L5683, L5700, L5701, L5702, L5703, L5704

Prosthetic sockets and inserts which do not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Suspension systems

Mechanical

Mechanical suspension systems including, belts, sleeves, straps, socket design features, and pin-locking mechanisms may be considered medically necessary when the prosthesis meets the above criteria, and the individual’s functional level is at least one (1).

L5666, L5670, L5671, L5672

Suction

Passive suction systems including, belts, sleeves, straps, socket design features, may be considered medically necessary when the prosthesis meets above criteria, and the individual’s functional level is at least two (2).

L5647, L5652

Vacuum suspension system

Vacuum suspension systems (e.g., vacuum-assisted socket system [VASS™]) may be considered medically necessary to control residual limb volume when there is contraindication to or failure of other socket-suspension systems (e.g., mechanical, passive suction) to adequately secure the limb to the prosthesis; and the individual’s functional level is at least a three (3).

L5781, L5782, L5783

A suspension system is considered not medically necessary in individuals who do not meet these criteria as there is insufficient evidence to support a conclusion supporting the health outcomes or benefits associated with this item.

Additions and accessories

Accessories such as sheaths, joints, lacers, belts, covers, socks, etc. may be considered medically necessary when these appliances aid in or are essential to the effective use of the prosthetic limb. Additions should be billed on the same claim as the base procedure when supplied at the same time as the base procedure.

L5615, L5617, L5637, L5676, L5677, L5680, L5682, L5684, L5686, L5688, L5690, L5692, L5694, L5696, L5698, L5705, L5706, L5707, L5722, L5724, L5726, L5728, L5780, L5785, L5790, L5795, L5807, L5815, L5855, L5910, L5925, L5926, L5940, L5960, L5962, L5964, L5966, L5968, L5971, L5975, L5985, L5988, L5990, L7367, L7368, L7600, L7700, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, L8480

Adjustments

Adjustments and/or modifications to the prosthesis required by wear and tear or due to a change in individual’s condition (such as growth in a child) or to improve the function are considered medically necessary.

Repairs

Repairs necessary to make the prosthetic functional are medically necessary. The expense for repairs may not exceed the estimated expense of purchasing another prosthesis.

L7510, L7520

Replacement

A replacement prosthesis including additions and accessories are medically necessary only if the previous prosthesis is no longer functional or there is documentation of irreparable damage. Requests for upgrades or newer technology will be reviewed for medical necessity.

Pediatric lower limb prostheses

Pediatric lower limb prostheses may be considered medically necessary for congenital and acquired pediatric limb deficiencies.

A child is eligible for prosthetics when they are able to stand on their own (approximately 9-12 months of age).

Components must be evaluated for age-appropriateness, considering comfort, weight, durability, and function.

A new socket and other prosthetic modifications are necessary at least once a year for children between the ages of birth to 18 years to allow for normal growth and development.

Pediatric lower limb prostheses which do not meet the criteria described above will be denied as not medically necessary as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Policy guidelines

Functional levels

Level 0 - Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.

Level 1 - Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.

Level 2 - Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

Level 3 - Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

Level 4 - Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

Patient selection and identification

Amputees should be evaluated by an independent qualified professional to determine the most appropriate prosthetic components and control mechanism. A trial period may be indicated to assess the tolerability and efficacy of the prosthesis in a real-life setting.

Decisions about the potential benefits of microprocessor-knees involve multiple factors including activity levels, as well as the patient’s physical and cognitive ability. A patient’s need for daily ambulation of at least 400 continuous yards, daily and frequent ambulation on uneven terrain (e.g., gravel, grass, curbs), and daily and frequent use of ramps and/or stairs (especially stair descent) should be considered as part of the decision. Typically, daily and frequent need of two or more of these activities would be needed to show benefit.

For patients in whom the potential benefits of the microprocessor knees are uncertain, patients may first be fitted with a standard prosthesis to determine their level of function with the standard device.

The following are guidelines from the Veterans Health Administration Prosthetic Clinical Management Program Clinical Practice Recommendations for Microprocessor Knees (Berry, 2000).

A. Contraindications for use of the microprocessor knee should include the following:

• Any condition that prevents socket fitting, such as a complicated wound or intractable pain which precludes socket wear.
• Inability to tolerate the weight of the prosthesis.
• Medicare level K0 – no ability or potential to ambulate or transfer.
• Medicare level K1 – limited ability to transfer or ambulate on level ground at fixed cadence.
• Medicare level K2 – limited community ambulator that does not have the cardiovascular reserve, strength, and balance to improve stability in stance to permit increased independence, less risk of falls, and potential to advance to a less-restrictive walking device.
• Inability to use swing and stance features of the knee unit.
• Poor balance or ataxia that limits ambulation.
• Significant hip flexion contracture (over 20 degrees).
• Significant deformity of remaining limb that would impair ability to stride.
• Limited cardiovascular and/or pulmonary reserve or profound weakness.
• Limited cognitive ability to understand gait sequencing or care requirements.
• Long distance or competitive running.
• Falls outside of recommended weight or height guidelines of manufacturer.
• Specific environmental factors—such as excessive moisture or dust, or inability to charge the prosthesis.
• Extremely rural conditions where maintenance ability is limited.

B. Indications for use of the microprocessor knee should include the following:

• Adequate cardiovascular and pulmonary reserve to ambulate at variable cadence.
• Adequate strength and balance in stride to activate the knee unit.
• Should not exceed the weight restrictions of the knee unit.
• Adequate cognitive ability to master technology and gait requirements of the device.
• Hemi-pelvectomy through knee-disarticulation level of amputation, including bilateral lower extremity amputees are candidates if they meet functional criteria as listed.
• The individual is an active walker and requires a device that reduces energy consumption to permit longer distances with less fatigue.
• Daily activities or job tasks that do not permit full focus of concentration on knee control and stability—such as uneven terrain, ramps, curbs, stairs, repetitive lifting, and/or carrying.
• Medicare level K2—limited community ambulator, but only if improved stability in stance permits increased independence, less risk of falls, and potential to advance to a less restrictive walking device, and patient has cardiovascular reserve, strength, and balance to use the prosthesis.
• Medicare level K3—unlimited community ambulator.
• Medicare level K4—active adult, athlete who has the need to function as a K3 level in daily activities.
• Potential to lessen back pain by providing more secure stance control, using less muscle contraction to keep knee stable.
• Potential to unload and decrease stress on remaining limb.
• Potential to return to an active lifestyle.

C. Physical and functional fitting criteria for new amputees:

• New amputees may be considered if they meet certain criteria as outlined above.
• Premorbid and current functional assessment important determinant.
• Requires stable wound and ability to fit socket.
• Immediate postoperative fit if possible.
• Must have potential to return to active lifestyle.

Cross-references

• MP 6.018 Prosthetics and Accessories
• MP 6.028 Foot-Orthotics and Other Podiatric Appliances
• MP 6.062 Ankle-Foot and Knee-Ankle-Foot Orthoses

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Lower extremity prosthetics

More than 100 different prosthetic ankle-foot and knee designs are currently available. The choice of the most appropriate design may depend on the patient’s underlying activity level. For example, the requirements of a prosthetic knee in an elderly, largely homebound individual will differ from those of a younger, active person. Key elements of a prosthetic knee design involve providing stability during both the stance and swing phase of the gait. Prosthetic knees vary in their ability to alter the cadence of the gait, or the ability to walk on uneven surfaces. In contrast to more simple prostheses, which are designed to function optimally at one walking cadence, fluid and hydraulic-controlled devices are designed to allow amputees to vary their walking speed by matching the movement of the shin portion of the prosthesis to the movement of the upper leg. For example, the rate at which the knee flexes after “toe-off” and then extends before heel strike depends in part on the mechanical characteristics of the prosthetic knee. If the resistance to flexion and extension of the joint does not vary with gait speed, the prosthetic knee extends too quickly or too slowly relative to the heel strike if the cadence is altered. When properly controlled, hydraulic or pneumatic swing-phase controls allow the prosthetist to set a pace adjusted to the individual amputee, from very slow to race-walking pace. Hydraulic prostheses are heavier than other prostheses and require gait training; for these reasons, these prostheses are prescribed for athletic or fit individuals. Other design features include multiple centers of rotation, referred to as “polycentric knees.” The mechanical complexity of these devices allows engineers to optimize selected stance and swing-phase features.

Microprocessor-controlled prosthetic knees

Microprocessor-controlled prosthetic knees have been developed, including the Intelligent Prosthesis (Blatchford, England); the Adaptive (Endolite, Basingstoke, Hampshire, UK); the Rhee Knee® (Össur, Iceland); the C-Leg® (Genium™ Bionic Prosthetic System, and the X2 and X3 prostheses (Otto Bock Orthopedic Industry, Minneapolis, MN); and Seattle Power Knees (3 models include Single Axis, 4-bar, and Fusion, from Seattle Systems). These devices are equipped with a sensor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern for varying speeds. The prosthetist can specify several different optimal adjustments that the computer later selects and applies according to the pace of ambulation. Also, these devices (with the exception of the Intelligent Prosthesis) use microprocessor control in both the swing and stance phases of gait. (The C-Leg Compact provides only stance control.) By improving stance control, such devices may provide increased safety, stability, and function; for example, the sensors are designed to recognize stumble and stiffen the knee, thus avoiding a fall. The potential benefits of microprocessor-controlled knee prostheses are improved ability to navigate stairs, slopes, and uneven terrain and reduction in energy expenditure and concentration required for ambulation.

In 1999, the C-Leg was cleared for marketing by the Food and Drug Administration (FDA) through the 510(k) process (K991590). Next-generation devices such as the Genium Bionic Prosthetic system and the X2 and X3 prostheses use additional environmental input (e.g., gyroscope and accelerometer) and more sophisticated processing that is intended to create more natural movement. One improvement in function is step-over-step stair and ramp ascent. They also allow the user to walk and run forward and backward. The X3 is a more rugged version of the X2 that can be used in water, sand, and mud. The X2 and X3 were developed by Otto Bock as part of the Military Amputee Research Program.

Powered knee prostheses

The Power Knee™ (Össur, Iceland), which is designed to replace muscle activity of the quadriceps, uses artificial proprioception sensors similar to the Proprio Foot to anticipate and respond with the appropriate movement required for the next step. The Power Knee is currently in the initial launch phase in the United States.

Microprocessor-controlled ankle-foot prostheses

Microprocessor-controlled ankle-foot prostheses are being developed for transtibial amputees. These include the Proprio Foot® (Össur), the iPED (developed by Martin Bionics, Oklahoma City, OK, and licensed to College Park Industries, Warren, MI), and the Elan Foot (Endolite). With sensors in the feet that determine the direction and speed of the foot’s movement, a microprocessor controls the flexion angle of the ankle, allowing the foot to lift during the swing phase and potentially improving the ease of free, speed, and terrain during the stance. This technology is designed to make ambulation more efficient and prevent falls in patients ranging from the young active amputee to the elderly diabetic patient. The Proprio Foot® and Elan Foot are microprocessor- controlled foot prostheses that are commercially available at this time and are considered class II devices that are exempt from 510(k) marketing clearance. Information on these devices indicates that they are appropriate for low- to moderate-impact for transtibial amputees who are classified as level K3 (i.e., community ambulatory, with the ability or potential for ambulation with variable cadence).

Powered ankle-foot prostheses

Powered ankle-foot prostheses that also replace muscle activity to bend and straighten the prosthetic ankle joint are under development. For example, the PowerFoot BiOM® (developed at the Massachusetts Institute of Technology and licensed to iWalk) is a myoelectric prosthesis for transtibial amputees that uses muscle activity in the remaining limb for the control of ankle movement (see evidence review 1.04.04 for a description of myoelectric technology). This prosthesis is designed to propel the foot forward as it pushes off the ground during the gait cycle, which is in addition to improving efficiency, has the potential to reduce hip and back problems arising from an unnatural gait with use of a passive prosthesis. This technology is limited by the size and weight required for a motor and batteries in the prosthesis.

Regulatory status

According to the manufacturers, microprocessor-controlled prostheses are considered a class I device by the U.S. Food and Drug Administration (FDA) and is exempt from 510(k) requirements. This classification does not require submission of clinical data regarding efficacy but only notification of FDA prior to marketing. FDA product codes: ISW, KFX.

Rationale

Microprocessor-controlled knee

The literature consists of a number of small within-subject comparisons of microprocessor- controlled knees to non-microprocessor-controlled knee joints. Studies of prostheses with microprocessor knees in Medicare-level K3 and K4 amputees have shown objective improvements in function on some outcome measures and strong patient preference for microprocessor-controlled prosthetic knees. The evidence in Medicare level K2 ambulators suggests that a prosthesis with stance control only can improve activities that require balance and improve walking in this population. Only one small randomized study of the next-generation Genium prosthesis was identified. One small study found little difference in performance between the Rhee Knee II and the users own non-microprocessor-controlled knee.

Microprocessor-controlled ankle-foot prostheses

Several small studies have been reported with microprocessor-controlled prostheses for transtibial amputees. The evidence to date is insufficient to support an improvement in functional outcomes when compared with the same device in the off-mode or compared with ESR prostheses. Larger, higher quality studies are needed to determine the impact of these devices on health outcomes with greater certainty.

Powered ankle-foot prostheses

Several small studies have been reported with powered ankle-foot prostheses for transtibial amputees. The evidence to date is insufficient to support an improvement in functional outcomes.

Summary of evidence

For individuals who have a transfemoral amputation who receive a prosthesis with a microprocessor- controlled knee, the evidence includes a number of small within-subject comparisons of microprocessor-controlled knees vs hydraulic knee joints. Relevant outcomes are functional outcomes, health status measures, and quality of life. For K3- and K4-level amputees, studies have shown objective improvements in function on some outcome measures and a strong patient preference for microprocessor-controlled prosthetic knees. Benefits include a more normal gait, an increase in stability, a decrease in falls, and a decrease in the cognitive burden associated with monitoring the prosthesis. For these reasons, a microprocessor-controlled knee may provide incremental benefit for these individuals. Those considered most likely to benefit from these devices have both the potential and need for frequent ambulation at variable cadence, an uneven terrain, or on stairs. The potential to achieve a high functional level with a microprocessor- controlled knee includes having the appropriate physical and cognitive ability to use the advanced technology. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Note that the evidence does not permit conclusions on the effect of a microprocessor-controlled prosthesis on health outcomes in limited community ambulators or on the effect of a next- generation microprocessor-controlled prosthesis on health outcomes.

For individuals who have a transfemoral amputation who receive a prosthesis with a powered knee, the evidence includes limited data. Relevant outcomes are functional outcomes, health status measures, and quality of life. The limited evidence available to date does not support an improvement in functional outcomes with a powered knee prosthesis compared with standard prostheses. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a tibial amputation who receive a prosthesis with a microprocessor- controlled ankle-foot, the evidence includes limited data. Relevant outcomes are functional outcomes, health status measures, and quality of life. The limited evidence available to date does not support an improvement in functional outcomes with microprocessor-controlled ankle-foot prostheses compared with standard prostheses. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have a tibial amputation who receive a prosthesis with a powered ankle-foot, the evidence includes no data. Relevant outcomes are functional outcomes, health status measures, and quality of life. The evidence is insufficient to determine the effects of the technology on health outcomes.

Definitions

N/A

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational; therefore, not covered

Medically necessary and therefore covered

References

1. Alimusaj M, Fradet L, Braatz F, et al. Kinematics and kinetics with an adaptive ankle foot system during stair ambulation of transtibial amputees. Gait Posture. Oct 2009; 30(3): 356-363. PMID 19616436
2. Au S, Berniker M, Herr H. Powered ankle-foot prosthesis to assist level-ground and stair-descent gaits. Neural Netw. May 2008; 21(4): 654-660. PMID 18499394
3. Bellmann M, Schmalz T, Ludwigs E, et al. Immediate effects of a new microprocessor-controlled prosthetic knee joint: a comparative biomechanical evaluation. Arch Phys Med Rehabil. Mar 2012; 93(3): 541-549. PMID 22373937
4. Berry D. Microprocessor prosthetic knees. Phys Med Rehabil Clin N Am. Feb 2006; 17(1): 91-113, vii. PMID 16517347
5. Burnfield JM, Eberly VJ, Gronley JK, et al. Impact of stance phase microprocessor-controlled knee prosthesis on ramp negotiation and community walking function in K2 level transfemoral amputees. Prosthet Orthot Int. Mar 2012; 36(1): 95-104. PMID 22223685
6. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Lower Limb Prostheses (L33787). Accessed June 15, 2022.
7. Darter BJ, Wilken JM. Energetic consequences of using a prosthesis with adaptive ankle motion during slope walking in persons with a transtibial amputation. Prosthet Orthot Int. Feb 2014; 38(1): 5-11. PMID 23525888
8. Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using intelligent prostheses and conventionally damped knee swing-phase control. Clin Rehabil. Jun 2005; 19(4): 398-403. PMID 15929508
9. Datta D, Howitt J. Conventional versus microchip controlled pneumatic swing phase control for transfemoral amputees: user’s verdict. Prosthet Orthot Int. Aug 1998; 22(2): 129-135. PMID 9747997
10. Delussu AS, Brunelli S, Paradisi F, et al. Assessment of the effects of carbon fiber and bionic foot during overground and treadmill walking in transtibial amputees. Gait Posture. Sep 2013; 38(4): 876-882. PMID 23702342
11. Department of Veterans Affairs. VA Prosthetics and Sensory Aids. 2006; Accessed June 15, 2022.
12. Eberly VJ, Mulroy SJ, Gronley JK, et al. Impact of a stance phase microprocessor-controlled knee prosthesis on level walking in lower functioning individuals with a transfemoral amputation. Prosthet Orthot Int. Dec 2014; 38(6): 447-455. PMID 24135259
13. Ferris AE, Aldridge JM, Rabago CA, et al. Evaluation of a powered ankle-foot prosthetic system during walking. Arch Phys Med Rehabil. Nov 2012; 93(11): 1911-1918. PMID 22732369
14. Flynn K. Short Report: Computerized lower limb prosthesis (VA Technology Assessment Program). No. 2000; Accessed June 15, 2022.
15. Fradet L, Alimusaj M, Braatz F, et al. Biomechanical analysis of ramp ambulation of transtibial amputees with an adaptive ankle foot system. Gait Posture. Jun 2010; 32(2): 191-198. PMID 20457526
16. Gailey RS, Gaunaurd I, Agrawal V, et al. Application of self-report and performance-based outcome measures to determine functional differences between four categories of prosthetic feet. J Rehabil Res Dev. 2012; 49(4): 597-612. PMID 22773262
17. Hafner BJ, Smith DG. Differences in function and safety between Medicare Functional Classification Level-2 and -3 transfemoral amputees and influence of prosthetic knee joint control. J Rehabil Res Dev. 2009; 46(3): 417-433. PMID 19675993
18. Hafner BJ, Willingham LL, Buell NC, et al. Evaluation of function, performance, and preference as transtibial amputees transition from mechanical to microprocessor control of the prosthetic knee. Arch Phys Med Rehabil. Feb 2007; 88(2): 207-217. PMID 17270509
19. Herr HM, Grabowski AM. Bionic ankle-foot prosthesis normalizes walking gait for persons with leg amputation. Proc Biol Sci. Feb 7 2012; 279(1728): 457-464. PMID 21752817
20. Highsmith MJ, Kahle JT, Bongiorni DR, et al. Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature. Prosthet Orthot Int. Dec 2010; 34(4): 362-377. PMID 20969495
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