Precertification required for inpatient; outpatient varies by product

Precertification/preauthorization is required for all inpatient services described in this policy; outpatient prior authorization requirements vary by product (Commercial Managed Care and Commercial PPO require prior authorization; Medicare HMO and Medicare PPO do not).

• Inpatient services: precertification/preauthorization IS REQUIRED for all products if performed inpatient.
• Outpatient services: prior authorization requirement depends on product — Commercial Managed Care and Commercial PPO require prior authorization; Medicare HMO and Medicare PPO do not.

Use Authorization Manager; prior authorization applies to PPO per policy clarifications

Submit prior authorization requests using Authorization Manager; the policy clarifies prior authorization procedures and applicability to PPO plans and other products.

• Use Authorization Manager to submit initial authorization requests and the Complete Prior Authorization Request Form (973).
• Policy history notes clarifications to prior authorization processes, including prior authorization information clarified for PPO plans (effective 6/1/2022).

Independent qualified professional evaluation required

An independent qualified professional must evaluate the amputee and verify that the member meets all medical necessity criteria and determine the most appropriate prosthetic components and control mechanism.

• The independent qualified professional must confirm eligibility criteria (amputation level, muscle signal adequacy, cognitive/neurologic function, absence of interfering comorbidities).
• They must determine whether body-powered, myoelectric, or a hybrid system is most appropriate and verify the member meets the device criteria.

Adhere to administrative and coding clarifications in policy history

Follow the policy's administrative notes and coding clarifications when preparing authorization requests and documentation.

• Policy history includes multiple clarifications to coding information and administrative process; ensure submitted coding matches policy-listed HCPCS/ICD-10 procedure codes.
• Confirm that requested device meets the medical necessity criteria before submission to avoid administrative delays.

Submit requests through Authorization Manager (fax for out‑of‑network) with supporting clinical documentation

Providers must submit prior authorization requests via Authorization Manager (or fax for out-of-network) and include clinical documentation demonstrating the member meets medical necessity criteria, including independent evaluation and functional evaluation results.

• Enter facility NPI/provider ID and servicing provider NPI as instructed in Authorization Manager.
• Include clinical documentation that demonstrates amputation level, body-powered insufficiency, residual musculature meets microvolt threshold, cognitive/neurologic status, absence of interfering comorbidities, and functional evaluation outcomes.

Provide documentation per updated prior authorization and coding clarifications

Policy history clarifies prior authorization processes (including use of Authorization Manager) and coding; provide required documentation and follow policy coding when requesting authorization.

• Policy history entries note clarifications to prior authorization procedures and coding information—review these when preparing requests.
• For out-of-network providers, fax prior authorization requests to 888-282-0780 as specified.

Advanced sensor/myoelectric devices and individually powered-digit prostheses are investigational

Requests for advanced devices with both sensor and myoelectric control (e.g., LUKE Arm), prostheses with individually powered digits (including partial-hand devices), and myoelectric-controlled upper-limb orthoses are considered investigational and may be denied.

• Advanced sensor + myoelectric devices (example: LUKE Arm) are explicitly labeled INVESTIGATIONAL.
• Prostheses with individually powered digits and myoelectric orthoses are also considered INVESTIGATIONAL and excluded from coverage.

Not obtaining required preauthorization may lead to denial or delayed payment

Failure to obtain required precertification/preauthorization for inpatient services or required outpatient prior authorization (per product rules) may result in claim denial or delayed payment.

• Inpatient procedures without required precertification/preauthorization may be denied.
• Outpatient procedures performed without required prior authorization for applicable products (e.g., Commercial PPO) may be denied or delayed.

PPO prior authorization clarifications — use Authorization Manager to submit requests

Prior authorization requirements for PPO plans and procedures may be submitted using Authorization Manager; the policy history documents clarifications to prior authorization processes including PPO applicability.

• Policy history notes that prior authorization information was clarified for PPO plans (effective 6/1/2022).
• Authorization Manager is the primary submission tool for initial authorization requests and prior authorization forms.