Lower Limb Prostheses

Affected Providers

Physicians and non-physician practitioners who write prescriptions for lower limb prostheses.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for lower limb prostheses is 5.7%, with a projected improper payment amount of $20.4 million.

We cover lower limb prostheses under the DME benefit. You must meet reasonable and necessary requirements.

We outline other policy requirements in LCD L33787 and Article: Lower Limb Prostheses (A52496).

We cover a lower limb prosthesis when the patient:

• Reaches or keeps a defined functional state within a reasonable period
• Is motivated to ambulate

Preventing Denials

We base a medical necessity determination for certain prosthesis parts and additions on a patient’s potential functional abilities. We base potential functional ability on the prosthetist’s and treating practitioner’s reasonable expectations and on factors including, but not limited to, the patient’s:

• History (including earlier prosthetic use, if applicable)
• Current condition (including the status of residual limb and nature of other medical problems)
• Wish to ambulate

We base clinical assessments of the patient’s rehabilitation potential on these classification levels:

• Level 0: Doesn’t have the ability or potential to ambulate or transfer safely with or without help, and a prosthesis doesn’t enhance their quality of life or mobility. The patient:
  • Doesn’t have sufficient cognitive ability to safely use a prosthesis with or without help
  • Requires help from equipment or a caregiver to transfer, and using a prosthesis doesn’t improve mobility or independence with transfers
  • Is wheelchair-dependent for mobility, and using a prosthesis doesn’t improve transfer abilities
  • Is bedridden and has no need or capacity to ambulate or transfer
• Level 1: The ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence, typical of a limited and unlimited household ambulator. The patient:
  • Has sufficient cognitive ability to safely use a prosthesis with or without an assistive device or the assistance or supervision of 1 person
  • Is capable of safe but limited ambulation within the home or on a similar flat surface like a home, with or without an assistive device or the assistance or supervision of 1 person
  • Requires a wheelchair for most activities outside their home
  • Isn’t capable of most of the functional activities designated in Level 2
• Level 2: The ability or potential for ambulation, with the ability to make their way across low-level environmental barriers (for example, curbs, stairs, or uneven surfaces), typical of a limited community ambulator. The patient:
  • Can, with or without an assistive device (which may include 1 or 2 handrails) or with or without the assistance or supervision of 1 person:
    • Perform the Level 1 tasks
    • Ambulate on a flat, smooth surface (for example, concrete, asphalt) that might be outside the home (for example, porch, deck, patio, garage, driveway)
    • Negotiate a curb
    • Access public or private transportation
    • Negotiate 1 or 2 stairs
    • Negotiate a ramp built to Americans with Disabilities Act (ADA) specifications
  • May require a wheelchair for distances that are beyond the perimeters of the home (for example, the yard, driveway, apartment building)
  • Is only able to increase their generally observed walking speed for short distances or with great effort
  • Is generally not capable of accomplishing most of the Level 3 tasks (or does so infrequently with great effort)
• Level 3: The ability or potential for ambulation with a variable cadence, typical of a community ambulator who can make their way across most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple movement. The patient:
  • Is independently capable (requiring no personal assistance or supervision), with or without an assistive device (which may include 1 or 2 handrails), of performing the Level 2 tasks and can:
    • Walk on terrain that varies in texture and level (for example, grass, gravel, uneven concrete)
    • Negotiate 3–7 consecutive stairs
    • Walk up and down ramps built to ADA specifications
    • Open and close doors
    • Ambulate through a crowded area (for example, grocery store, big box store, restaurant)
    • Cross a controlled intersection in their community within the time limit provided (varies by location)
    • Access public or private transportation
    • Perform dual ambulation tasks (for example, carry an item or meaningfully converse while ambulating)
  • Doesn’t perform the activities of Level 4
• Level 4: The ability or potential for prosthetic ambulation that exceeds basic ambulation skills, showing high impact, stress, or energy levels typical of the prosthetic demands of a child, active adult, or athlete. With or without an assistive device (which may include 1 or 2 handrails), the patient is independently capable (requiring no personal assistance or supervision) of performing high-impact domestic, vocational, or recreational activities like:
  • Running
  • Repetitive stair climbing
  • Climbing steep hills
  • Being a caregiver for another person
  • Home maintenance (for example, repairs, cleaning)

Medical records must document the patient’s current functional ability and their expected functional potential, including an explanation for the difference if that’s the case. Within functional classification hierarchy, we recognize that bilateral amputees often can’t be strictly bound by functional level classifications.

According to LCD L33787, both providers and suppliers must consider functional levels 0–4 when deciding on the proper prosthesis or code. Billing and coding staff must correctly report the patient’s expected functional level that the provider documents by using the HCPCS modifiers (for example, K0, K1 – K4, RT, LT).

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.