Description
When an initial or preparatory lower limb prosthesis is provided, some prosthetic substitution and/or addition codes are excluded and will be denied as not reasonable and necessary when billed with the initial or preparatory lower limb prosthesis.
Affected Code(s)
L5610, L5620, L5624, L5629, L5631, L5638, L5639, L5640, L5642, L5644, L5645, L5646, L5647, L5648, L5651, L5652, L5670, L5676, L5704, L5705, L5706, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5785, L5790, L5795, L5962, L5964, L5966, L5980
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5. 42 CFR §405.929- Post-Payment Review
6. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7. 42 CFR §405.986- Good Cause for Reopening
8. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions
9. 42 CFR, §414.210(f)- Payment for Replacement of Equipment
10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120- Prosthetic Devices
11. Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
12. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L33787-Lower Limb Prostheses; Effective 10/01/2015, Revised 04/01/2026
15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52496- Lower Limb Prostheses- Policy Article; Effective 10/01/2015, Revised 08/01/2026
16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024
17. HCPCS Level II Codebook