HCPCS L5280: Hemipelvectomy Prosthesis with Molded Socket and Single-Axis Knee - OpenPayer

Summary & Overview

HCPCS L5280: Hemipelvectomy Prosthesis with Molded Socket and Single-Axis Knee

HCPCS Level II code L5280 represents a comprehensive prosthetic assembly for patients who have undergone a hemipelvectomy (Canadian type), incorporating a molded socket, hip joint, single-axis constant-friction knee, shin, and SACH foot. This code captures a complex, high-cost prosthetic intervention that is clinically significant for limb-loss rehabilitation and mobility restoration at a national level.

Key payers in the coverage landscape include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of coverage and billing considerations across major payers, typical sites of service where this prosthesis is provided, and clinical context that informs coding and utilization. The publication provides benchmarks where available, notes common coding practices, and summarizes relevant policy elements that affect reimbursement and authorization for high-complexity lower‑extremity prostheses.

This summary is intended for billing professionals, prosthetists, rehabilitation clinicians, and policy analysts who need a concise reference on L5280 for national-level planning, claims processing, and clinical program development.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareL5280HCPCS Level IIhemipelvectomy prosthesislower-limb prostheticsprosthetic device codingsingle-axis kneeSACH footmolded socketprosthetics and orthotics

Billing Code Overview

HCPCS Level II code L5280 describes a prosthetic device for a patient undergoing a hemipelvectomy of the Canadian type. The specified device includes a molded socket, a hip joint, a single-axis constant friction knee, a shin, and a SACH foot.

Service type: Prosthetic lower-limb device fabrication and fitting for major limb loss involving the hemipelvis.
Typical site of service: Prosthetics and orthotics clinic, outpatient prosthetic facility, or specialized limb-loss rehabilitation center.

Clinical & Coding Specifications

Clinical Context

A 62-year-old patient with a malignant pelvic sarcoma involving the hemipelvis undergoes a surgical hemipelvectomy with subsequent fitting of a prosthesis described by L5280 (Canadian-type hemipelvectomy socket; molded socket, hip joint, single axis constant friction knee, shin, SACH foot). The clinical workflow begins with preoperative oncology and orthopedic assessment, imaging (pelvic MRI/CT) and multidisciplinary tumor board review to confirm limb-sparing is not feasible. After hemipelvectomy and appropriate wound healing, the patient is referred to a prosthetist and rehabilitation team. A molded Canadian-style hemipelvectomy socket is fabricated and aligned with a hip joint and a single-axis constant-friction knee and a SACH foot for initial ambulation training. Prosthetic fitting visits include casting or digital scanning, iterative socket adjustments, baseline alignment, gait training with physical therapy, and follow-up visits for skin checks, pressure-relief adjustments, and component replacements. Typical sites of service include outpatient prosthetics clinics, specialized orthotics and prosthetics (O&P) centers, inpatient rehabilitation units, and outpatient physical therapy clinics. Payors commonly involved in authorization and coverage determinations include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.

Coding Specifications

Modifier	Description	When to Use
`50`	Bilateral procedure

HCPCS L5970: Lower Extremity Prosthesis Foot, External Keel SACH

HCPCS-L5595-HIP-DISARTICULATION-HEMIPELVECTOMY-PREPARATORY-PYLON-SACH-FOOT

HCPCS L5595: Preparatory Pylon for Hip Disarticulation/Hemipelvectomy

HCPCS-L8499-MISCELLANEOUS-PROSTHETIC-SERVICES-UNLISTED

HCPCS L8499: Unlisted Procedure for Miscellaneous Prosthetic Services

HCPCS-L5010-PARTIAL-FOOT-MOLDED-SOCKET-ANKLE-HEIGHT-TOE-FILLER

HCPCS L5010: Partial Foot Molded Socket, Ankle Height, with Toe Filler

HCPCS-L7364-TWELVE-VOLT-BATTERY-DURABLE-MEDICAL-EQUIPMENT

HCPCS L7364: Twelve Volt Battery, Durable Medical Equipment

HCPCS-L5570-PREPARATORY-ABOVE-KNEE-KNEE-DISARTICULATION-ISCHIAL-SOCKET-PYLON

HCPCS L5570: Preparatory Above-Knee Prosthetic with Ischial Socket and Pylon

HCPCS-L6588-SHOULDER-DISARTICULATION-PREPARATORY-PLASTIC-SOCKET

HCPCS L6588: Preparatory Shoulder Disarticulation Plastic Socket

HCPCS-LEVEL-II-L6615-UPPER-EXTREMITY-LOCKING-WRIST-UNIT-DISCONNECT

HCPCS Level II L6615: Upper Extremity Addition, Disconnect Locking Wrist Unit

HCPCS-L8627-COCHLEAR-IMPLANT-EXTERNAL-SPEECH-PROCESSOR-REPLACEMENT

HCPCS L8627: Cochlear Implant External Speech Processor, Replacement

HCPCS-L6706-MECHANICAL-HOOK-TERMINAL-DEVICE

HCPCS L6706: Mechanical Voluntary-Opening Hook Terminal Device

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Taxonomy Code	Specialty	Notes
`334N00000X`	Orthotic and Prosthetic Practitioner	Primary specialty responsible for prosthesis design, fabrication, fitting, and adjustments.
`208800000X`	Orthopedic Surgery	Surgeon performing hemipelvectomy and coordinating residual-limb preparation for prosthetic fitting.
`2084P0800X`	Physical Medicine & Rehabilitation	Physiatrist managing rehabilitation planning, prosthetic prescription, and functional goals.
`225100000X`	Physical Therapist	Provides gait training, functional mobility training, and therapeutic interventions post-fitting.
`263QM0800X`	General Practice (Wound/Hyperbaric Specialist)	Manages wound healing and residual-limb skin integrity prior to prosthetic fitting.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C41.4`	Malignant neoplasm of pelvic bones	Common indication for hemipelvectomy when tumor invades pelvic bones, necessitating pelvic-level amputation and subsequent prosthesis.
`C49.5`	Malignant neoplasm of connective and soft tissue of pelvis	Soft-tissue sarcomas in the pelvis often require radical resection and prosthetic rehabilitation.
`M84.371A`	Pathologic fracture, pelvic region, initial encounter for fracture	Pathologic fractures from malignancy or severe osteopathy may lead to hemipelvectomy and prosthetic need.
`T84.84XA`	Periprosthetic fracture of internal prosthetic device, initial encounter	Relevant when prior implants fail or are complicated, leading to complex reconstruction and prosthetic planning.
`S37.839A`	Injury of unspecified pelvic organ, initial encounter	Severe traumatic pelvic injuries can necessitate hemipelvectomy and subsequent prosthetic fitting.
`L89.XXX`	Pressure ulcer of unspecified part of pelvis	Chronic wounds or pressure ulcers on the residual pelvis affect timing and design of socket fitting.
`Z89.611`	Acquired absence of thigh, right leg above knee	Reflects limb loss and supports prosthetic coverage and justification for `L5280` when documented for pelvic-level amputation.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97760`	Orthotic(s) and/or prosthetic(s) initial fitting and training, upper and/or lower extremity; first device	Used for initial prosthetic fitting and patient training after delivery of the hemipelvectomy prosthesis described by `L5280`.
`97761`	Orthotic(s) and/or prosthetic(s) subsequent management, established patient; lower limb prosthetic treatment	Applied for follow-up prosthetic training sessions and adjustments after the initial fitting.
`97763`	Orthotic and prosthetic evaluation with fitting and training	Used for evaluation and measurement/assessment sessions that lead to fabrication of the prosthesis.
`29580`	Application of external fixation device; pelvis	If temporary external fixation or pelvic stabilization procedures are required prior to definitive surgery and prosthetic planning.
`11043`	Debridement, muscle and/or fascia, and bone when performed; lower extremity (extensive)	Used when surgical debridement of infected or nonviable tissue of the residual pelvic/hip region is required before prosthetic fitting.

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