L5341 Hemipelvectomy (HCPCS) Reimbursement Benchmarks | OpenPayer

Summary & Overview

HCPCS L5341: Hemipelvectomy Prosthesis, Canadian Molded Socket

HCPCS Level II code L5341 represents a specialized prosthetic device for patients who have undergone a hemipelvectomy, specifying a Canadian-type molded pelvic socket built on an endoskeletal system with an integrated hip joint, single-axis knee, and SACH foot. This code is used when billing for fabrication, assembly, and fitting of a complex lower-extremity prosthesis tailored to pelvic-level amputation. Nationally, the code matters because it captures high-cost, specialized prosthetic services that impact durable medical equipment and prosthetics budgets and care coordination for amputee patients.

Key payers in typical coverage analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for L5341, typical sites of service, and what types of benchmarks and policy issues are relevant for specialized prosthetic codes. The publication will cover reimbursement benchmarks, prior authorization and documentation considerations commonly encountered with high-complexity prosthetic claims, and policy developments affecting durable medical equipment and prosthetics payment. It will also provide guidance on claim components and service lines associated with complex pelvic-level prostheses. Data not available in the input are noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareL5341HCPCS Level IIprostheticshemipelvectomylower-extremity prosthesisendoskeletalpelvic-socketSACH footprosthetic fitting

Billing Code Overview

HCPCS Level II code L5341 describes a hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot prosthetic assembly. This represents a custom lower-extremity prosthesis designed for patients who have undergone hemipelvectomy amputation and require a molded pelvic-socket interface with an internal (endoskeletal) structural frame, an integrated hip joint, a single-axis knee joint, and a SACH (solid ankle cushion heel) foot.

Service Type: Prosthetic lower-extremity fabrication and fitting

Typical Site of Service: Prosthetics clinic or outpatient orthotics/prosthetics facility

Clinical & Coding Specifications

Clinical Context

A 62-year-old male with a history of recurrent high-grade sarcoma of the hemipelvis presents after failed limb-sparing surgery and radiation. Tumor invasion of the ilium and acetabulum with uncontrolled local pain, recurrent infection, and loss of function prompts a surgical hemipelvectomy. The prosthetic prescription is for a Canadian-style hemipelvectomy socket fabricated as a molded socket on an endoskeletal hip-knee-foot system with a single-axis knee and SACH foot, coded as L5341.

The clinical workflow includes preoperative evaluation by orthopedic oncology and physical medicine and rehabilitation, pre-prosthetic imaging and templating, surgical hemipelvectomy performed in an inpatient hospital operating room, postoperative wound care and inpatient rehabilitation for transfer and mobility training, prosthetic fabrication by a prosthetist using a molded socket pattern, fitting and alignment sessions, and outpatient follow-up for adjustments and gait training. Typical site of service is an inpatient hospital for the amputation and early postoperative care, with subsequent prosthetic fabrication and fittings occurring in an outpatient prosthetics clinic or rehabilitation facility.

Coding Specifications

Modifier	Description	When to Use
`50`	Bilateral Procedure	When a bilateral hemipelvectomy prosthesis or bilateral services are furnished (rare; use when applicable).

HCPCS L6709: Mechanical Voluntary-Closing Prosthetic Hand

HCPCS-L5661-LOWER-EXTREMITY-SOCKET-INSERT-MULTI-DUROMETER-SYMES

HCPCS L5661: Addition to Lower Extremity Socket Insert, Multi-Durometer Symes

HCPCS-L5925-ENDOSKELETAL-ABOVE-KNEE-KNEE-HIP-DISARTICULATION-MANUAL-LOCK

HCPCS L5925: Endoskeletal Addition for Above-Knee or Hip Disarticulation, Manual Lock

HCPCS-L7510-PROSTHETIC-REPAIR-MINOR-PARTS

HCPCS L7510: Repair of Prosthetic Device, Minor Parts

HCPCS-L5540-PREPARATORY-BELOW-KNEE-PTB-SOCKET-SACH-FOOT

HCPCS L5540: Preparatory Below-Knee PTB Socket with SACH Foot

HCPCS-L5105-BELOW-KNEE-PLASTIC-SOCKET-SACH-FOOT

HCPCS L5105: Below-Knee Plastic Socket with Joints and SACH Foot

HCPCS-L5210-ABOVE-KNEE-SHORT-PROSTHESIS-STUBBIES

HCPCS L5210: Above-Knee Short Prosthesis Without Knee Joint

HCPCS-L6692-UPPER-EXTREMITY-SILICONE-GEL-INSERT

HCPCS L6692: Upper Extremity Silicone Gel Insert, Prosthetic Accessory

HCPCS-L5301-BELOW-KNEE-MOLDED-SOCKET-SACH-FOOT-ENDOSKELETAL

HCPCS L5301: Below-Knee Molded Socket with SACH Foot, Endoskeletal System

HCPCS-L5972-LOWER-EXTREMITY-PROSTHETIC-FOOT-FLEXIBLE-KEEL

HCPCS L5972: Lower Extremity Prosthetic Foot, Flexible Keel

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Taxonomy Code	Specialty	Notes
`208000000X`	Orthopaedic Surgery	Primary surgical specialty performing hemipelvectomy and managing operative care.
`2086S0105X`	Surgical Oncology	Surgeons specializing in oncologic resections of pelvic malignancies.
`208100000X`	Physical Medicine & Rehabilitation	Leads prosthetic training and functional rehabilitation post-amputation.
`334N00000X`	Prosthetics & Orthotics	Certified prosthetists who fabricate, fit, and adjust the molded Canadian hemipelvectomy socket.
`207Q00000X`	General Surgery	May be involved in complex pelvic resections in some settings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C41.4`	Malignant neoplasm of pelvic bones	Pelvic bone sarcomas invading the acetabulum/ilium often necessitate hemipelvectomy and prosthetic reconstruction.
`C41.2`	Malignant neoplasm of hip bone and pelvis	Indicates primary malignant bone tumor leading to extensive resection and need for hemipelvectomy prosthesis.
`C49.5`	Malignant neoplasm of connective and soft tissue of pelvis	Soft tissue sarcomas with pelvic involvement that require radical resection and subsequent prosthetic rehabilitation.
`T84.84`	Infection and inflammatory reaction due to internal prosthetic device, implant and graft, pelvic region	Chronic infection complicating prior pelvic reconstruction or implants may lead to amputation and need for prosthesis.
`M96.89`	Other postprocedural musculoskeletal disorders	Postoperative complications after pelvic procedures that may culminate in hemipelvectomy.
`S31.89`	Other open wound of abdomen, lower back and pelvis	Severe traumatic pelvic injury with nonviable tissue that may require hemipelvectomy and prosthetic fitting.
`Z89.612`	Acquired absence of right hip joint	Amputation status codes used for prosthetic provisioning and billing; relevant for documenting laterality and prosthesis need.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`27599`	Unlisted procedure, femur or knee	Used when no specific CPT exists for the surgical hemipelvectomy portion billed by the surgeon; may be used for unusual pelvic amputations.
`97760`	Orthotic and prosthetic management and training, initial encounter (individual), per session	Used in outpatient or inpatient rehab for prosthetic training after delivery of the hemipelvectomy prosthesis.
`97761`	Prosthetic training, subsequent encounters	Used for ongoing training sessions after the initial evaluation.
`97763`	Orthotic/prosthetic management and training, initial, lower extremity prosthetic training, single component	Used when training focuses on a single prosthetic component; applicable to socket fitting and gait training.
`97750`	Physical performance test or measurement (e.g., musculoskeletal, functional capacity)	Used for baseline and progress functional assessments related to ambulation and prosthetic use.
`99070`	Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit	Used for nonstandard supplies or materials related to fitting and adjustments of the prosthesis.

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