Prior Authorization Required

Precertification/prior authorization is required for services described in this policy for commercial members when performed inpatient or outpatient. Submit prior authorization requests for commercial members using Authorization Manager. Authorization Manager is available 24/7 and is the preferred method to review requirements, request authorizations, submit clinical documentation, check case status, and view/print decision letters.

• Inpatient services: precertification/prior authorization IS REQUIRED.
• Outpatient services (Commercial Managed Care HMO/POS and Commercial PPO): prior authorization IS REQUIRED.
• Use Authorization Manager to submit initial authorization requests and clinical documentation.

Trial with Standard Prosthesis May Be Indicated

A trial fitting with a standard (non-microprocessor) prosthesis may be indicated for individuals when the potential benefit of a microprocessor-controlled knee is uncertain. Fitting a standard prosthesis first can help determine the member's functional level, durability, and tolerance of a prosthesis before authorizing a microprocessor-controlled device.

• Consider trial with standard prosthesis when benefit is uncertain.
• Use trial results (functional performance, distance ambulated, ability on uneven terrain/stairs) to support authorization decisions.

Required Clinical Documentation and Submission Method

Documentation submitted with the authorization request must support medical necessity and the individual's demonstrated physical and cognitive abilities. Include clinical evidence of daily ambulation needs (for example, regular long-distance ambulation, variable cadence, uneven terrain, or frequent stair/ramp use), cardiovascular and pulmonary reserve, strength/balance assessments, cognitive ability to use the device, and any trial fitting outcomes. Also include information addressing any contraindications.

• Include objective functional assessments (e.g., distance ambulated, K-level classification) and clinician evaluation.
• If a trial with a standard prosthesis was performed, submit trial duration and outcome measures.
• Provide documentation of device weight/height suitability and absence of contraindications (wound preventing socket fitting, inability to tolerate prosthesis weight, poor balance/ataxia, significant contracture or deformity, insufficient cardiovascular/pulmonary reserve, limited cognition, environmental/maintenance limitations).
• Enter facility NPI/provider ID and servicing provider NPI when submitting via Authorization Manager.

Contraindications That May Lead to Denial

Contraindications may lead to denial of coverage. Do not authorize microprocessor-controlled knees when contraindications are present.

• Conditions preventing socket fitting (complicated wound, intractable pain).
• Inability to tolerate prosthesis weight.
• Medicare K0 or K1 functional levels (no ability/potential to ambulate or limited to fixed-cadence ambulation).
• Poor balance or ataxia limiting ambulation; inability to use swing/stance features.
• Significant hip flexion contracture (>20°) or limb deformity impairing stride.
• Limited cardiovascular/pulmonary reserve or profound weakness; limited cognitive ability to understand gait sequencing/care.
• Environmental or maintenance barriers (excessive moisture/dust, inability to charge), extremes of weight/height outside device limits.

How to Request Authorization

Authorization Manager should be used to request prior authorization for commercial members per the 9/2023 policy clarification. Refer to Authorization Manager guidance to ensure accurate submission and timely processing.

• Authorization Manager is the required submission tool for initial authorization requests for commercial members.
• Ensure facility and servicing provider NPIs/IDs are entered correctly.
• For commercial members, requests must meet the medical policy guidelines to be approved.