A microprocessor-controlled prosthetic knee (e.g., C-Leg - codes L5828, L5845, L5848, L5856, L5920, L5930, L5950) is covered for patients whose functional level is 3 or above, as indicated by modifier K3 or K4. When provided for a functional level other than 3 or above, the microprocessor-controlled prosthetic knee will be denied as not medically necessary. Effective January 26, 2009, a participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records.

On-board, real-time gait analysis is accomplished by the microprocessors in this knee (L5828, L5845, L5848, L5856, L5920, L5930, L5950). Separate payment will not be made for the gait analysis if billed separately under code L5999. The allowance for this function is included in the reimbursement for codes L5828, L5845, L5848, L5856, L5920, L5930 and L5950. A network provider cannot bill the member for the denied service.

A determination of medical necessity for the microprocessor-controlled prosthetic knee is based on the patient'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 patient's past history (including prior prosthetic use if applicable); and
  
  
• The patient's current condition including the status of the residual limb and the nature of other medical problems; and
  
  
• The patient's desire to ambulate.

Clinical assessments of patient rehabilitation potential must be based on the following classification levels:

• Level 0 (indicated by modifier K0): 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 (indicated by modifier K1): 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 (indicated by modifier K2): 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 (indicated by modifier K3): 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 (indicated by modifier K4): 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.

The records must document the patient's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if one exists.

NOTE:

Bilateral amputees often cannot be strictly bound by functional level classifications.

When submitting a claim for the microprocessor-controlled prosthetic knee, the billed code(s) (L5828, L5845, L5848, L5856, L5920, L5930, L5950) must be submitted with modifiers K0 - K4, indicating the expected patient functional level. The expected patient functional ability information must be clearly documented and retained in the prosthetist's records, in addition to information about the patient's history and current condition which supports the designation of the functional level by the prosthetist.

Reimbursement may be made only if there is sufficient documentation in the patient’s medical record showing functional need for the technologic or design feature of the microprocessor-controlled prosthetic knee. This information must be retained in the physician’s or prosthetist’s files, and be available upon request.

Coverage for Prosthetics and Orthotics is determined according to individual or group customer benefits.

Description

The microprocessor-controlled prosthetic knee is designed for lower limb amputees. It is 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 of varying speeds. The prosthetist can specify several different optimal adjustments that the computer later selects and applies according to the pace of ambulation. The C-Leg prosthetic knee is also designed to improve the stance control, e.g., it may be possible for the sensors to recognize a stumble, stiffen the knee, and avoid a fall.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Computerized Lower Limb Prostheses, VA Technology Assessment Program Short Report, No. 2, Boston, Mass: MDRC, March 2000

Lower Limb Prostheses, Region A DMERC LMRP LLP20030401