Priority Health prosthetics coverage & Prior Auth

Medical necessity for prosthetics

Covered when ALL of the following are met

Basic coverage criteria: Prosthetic devices are covered when needed to restore function to all or part of a permanently inoperative, malfunctioning, or absent body partpermanence indicated by ordering physician

The test of permanence is met if the ordering physician indicates the condition is of long and indefinite duration

Repair and Replacement Criteria

Replacement/Repair covered when meeting listed conditions

Repair/replacement: Repairs or maintenance as a result of normal use are a covered benefit; repairs or maintenance due to misuse or abuse are not covered and are the responsibility of the member

Replacement of a prosthesis damaged by normal use or required due to body growth is covered. Replacement for misuse/abuse or for lost or stolen prosthetics is not covered. Requests to replace an undamaged device require a physician statement documenting a change in condition; decision to replace or upgrade is at the discretion of the Health Management Department

K-level Eligibility

Not covered when the following applies

K-level exclusions: Prosthetic appliances for a member with a potential functional level of K0 are not coveredK0

K-level definitions K0–K4 are provided in the policy; K0 indicates no ability or potential to ambulate or transfer safely and prosthesis does not enhance quality of life or mobility

Osseointegrated Prostheses (Not Covered)

Osseointegrated devices: Osseointegrated/osseoanchored lower limb prosthetic devices (e.g., OPRA Implant System) are considered experimental, investigational, or unproven and are not medically necessary

The OPRA system is described (FDA PMA status and device details) in background, but these devices are listed as not covered per policy

The policy lists several general exclusions. Examples of items that are not covered include artificial teeth (dentures, crowns, implants) and related dental prostheses, hearing aids except where a commercial hearing-aid rider applies or for Medicaid/Healthy Michigan Plan members, wigs, and any cosmetic or convenience customization of a prosthetic device. These are explicit limits to coverage; members and providers should refer to the member’s plan documents for any hearing-aid rider or state-specific benefits.

Replacement and repair are covered only under specific circumstances. Repairs or maintenance due to normal use and replacement required because of damage from normal use or body growth are covered. In contrast, repairs or replacements resulting from misuse or abuse and replacement of lost or stolen prosthetics are not covered and are the member’s financial responsibility. Requests to replace an undamaged device require a physician statement documenting a change in the member’s condition; final decisions rest with the Health Management Department.

The HCPCS code L5991 (Addition to lower extremity prostheses, osseointegrated external prosthetic connector) is explicitly designated as Not covered for any lines of business in the policy and will not be reimbursed.

The policy’s Not Covered list includes specific items and codes that will not be covered. Examples called out are A9282 (wig, any type), E3200 (gait modulation system, rhythmic auditory stimulation), L8035 (custom breast prosthesis, post-mastectomy, molded to patient model), and the unlisted/procedure codes 0964T–0966T for jaw expansion oral prostheses. Claims for these items will be denied as not covered.

Osseointegrated (bone‑anchored) lower limb prosthetic systems — for example, the OPRA Implant System — are discussed in the background but are considered experimental, investigational, or unproven for the purposes of this policy and are therefore not medically necessary and not covered. Although the OPRA system has an FDA PMA, the policy states that clinical evidence is insufficient to support routine coverage and explicitly lists osseointegrated/osseoanchored devices as not covered.

HCPCS / CPT / ICD-10 Codes

CPT/HCPCS Lower Limb Codes (listed)HCPCS

L3161	Foot, adductus positioning device, adjustable.
L5000	Partial foot, shoe insert with longitudinal arch, toe filler.
L5010	Partial foot, molded socket, ankle height, with toe filler.
L5020	Partial foot, molded socket, tibial tubercle height, with toe filler.
L5050	Ankle, Symes, molded socket, SACH foot.
L5060	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot.
L5100	Below knee, molded socket, shin, SACH foot.
L5105	Below knee, plastic socket, joints and thigh lacer, SACH foot.
L5150	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot.
L5160	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot.

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Preparatory sockets (examples)HCPCS

L5510	Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model
L5520	Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed
L5530	Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model
L5535	Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket
L5540	Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model
L5560	Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model
L5570	Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed
L5580	Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model
L5585	Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket

Lower extremity additions and test socketsHCPCS

L5590	Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model
L5595	Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model
L5600	Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model
L5610	Addition to lower extremity, endoskeletal system, above knee, hydracadence system
L5611	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control
L5613	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control
L5614	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control
L5615	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
L5616	Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control
L5617	Addition to lower extremity, quick change self-aligning unit, above or below knee, each

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Socket types and materialsHCPCS

L5630	Addition to lower extremity, Symes type, expandable wall socket
L5631	Addition to lower extremity, above knee or knee disarticulation, acrylic socket
L5632	Addition to lower extremity, Symes type, PTB brim design socket
L5634	Addition to lower extremity, Symes type, posterior opening (Canadian) socket
L5636	Addition to lower extremity, Symes type, medial opening socket
L5637	Addition to lower extremity, below knee, total contact
L5638	Addition to lower extremity, below knee, leather socket
L5639	Addition to lower extremity, below knee, wood socket
L5640	Addition to lower extremity, knee disarticulation, leather socket
L5642	Addition to lower extremity, above knee, leather socket

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Socket inserts and suspensionHCPCS

L5650	Addition to lower extremity, total contact, above knee or knee disarticulation socket
L5651	Addition to lower extremity, above knee, flexible inner socket, external frame
L5652	Addition to lower extremity, suction suspension, above knee or knee disarticulation socket
L5653	Addition to lower extremity, knee disarticulation, expandable wall socket
L5654	Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal)
L5655	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, ...)
L5656	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)
L5657	Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials
L5658	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

Additional lower extremity components and jointsHCPCS

L5661	Addition to lower extremity, socket insert, multidurometer, Symes
L5665	Addition to lower extremity, socket insert, multidurometer, below knee
L5666	Addition to lower extremity, below knee, cuff suspension
L5668	Addition to lower extremity, below knee, molded distal cushion
L5670	Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar)
L5671	Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert
L5672	Addition to lower extremity, below knee, removable medial brim suspension
L5673	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism
L5676	Addition to lower extremity, below knee, knee joints, single axis, pair
L5677	Addition to lower extremity, below knee, knee joints, polycentric, pair

Advanced components (vacuum, microprocessor, powered)HCPCS

L5781	Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system
L5782	Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty
L5810	Addition, endoskeletal system, below knee, alignable system
L5920	Addition, endoskeletal system, above knee or hip disarticulation, alignable system
L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
L5857	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type
L5858	Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)
L5973	Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source

Foot components and explicit non-coverageHCPCS

L5991	Addition to lower extremity prostheses, osseointegrated external prosthetic connector (Not covered for any lines of business)
L5970	All lower extremity prostheses, foot, external keel, SACH foot
L5971	All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only
L5976	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)
L5980	All lower extremity prostheses, flex-foot system

Upper extremity prosthetic codes and additionsHCPCS

L6026	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)
L6032	Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)
L6035	Single prosthetic digit, mechanical, ... initial issue or replacement
L6037	Immediate post-surgical or early fitting, application of initial rigid dressing ... partial hand including fingers
L6050	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
L6100	Below elbow, molded socket, flexible elbow hinge, triceps pad
L6200	Elbow disarticulation, molded socket, outside locking hinge, forearm
L6250	Above elbow, molded double wall socket, internal locking elbow, forearm
L6300	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm
L6360	Interscapular thoracic, passive restoration (complete prosthesis)

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Covered HCPCS and related codes listedHCPCSCovered

L6647	Upper extremity addition, shoulder lock mechanism, body powered actuator
L6648	Upper extremity addition, shoulder lock mechanism, external powered actuator
L6650	Upper extremity addition, shoulder universal joint, each
L6655	Upper extremity addition, standard control cable, extra
L6660	Upper extremity addition, heavy duty control cable
L6665	Upper extremity addition, Teflon, or equal, cable lining
L6670	Upper extremity addition, hook to hand, cable adapter
L6672	Upper extremity addition, harness, chest or shoulder, saddle type
L6675	Upper extremity addition, harness, figure of eight type, single cable
L6676	Upper extremity addition, harness, figure of eight type, dual cable

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Not CoveredmixedNot Covered

A9282	Wig, any type, each
E3200	Gait modulation system, rhythmic auditory stimulation, including restricted therapy software
L8035	Custom breast prosthesis, post mastectomy, molded to patient model
0964T	Impression and custom preparation of jaw expansion oral prosthesis, single arch
0965T	Impression and custom preparation of jaw expansion oral prosthesis, dual arch non-fixed hinge
0966T	Impression and custom preparation of jaw expansion oral prosthesis, dual arch fixed hinge

ICD-10 Codes that support medical necessityICD-10

C50.011 - C50.929	Malignant neoplasm of breast (range)
C79.81	Secondary malignant neoplasm of breast
D05.00 - D05.92	Carcinoma in situ of breast (range)
D07.30	Carcinoma in situ of unspecified female genital organs
Z40.01	Encounter for prophylactic removal of breast
Z42.1	Encounter for breast reconstruction following mastectomy
Z42.8	Encounter for other plastic and reconstructive surgery following medical procedure or healed injury
Z85.3	Personal history of malignant neoplasm of breast
Z90.10 - Z90.13	Acquired absence of breast and nipple (range)
Z98.82	Breast implant status

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Unlisted codes (require explanatory notes)HCPCS

L5999	Lower extremity prosthesis, not otherwise specified (unlisted)
L7499	Upper extremity prosthesis, NOS (unlisted)
L8499	Unlisted procedure for miscellaneous prosthetic services
L8699	Prosthetic implant, not otherwise specified
L9900	Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

Preauthorization dollar thresholds

Standard plans thresholdPreauthorization required for prosthetic items > $1,000

Medicaid / Healthy Michigan Plan thresholdPreauthorization required for prosthetic items > $500

Purpose of thresholdTriggers prior authorization requirement to demonstrate medical necessity per provider manual

Billing, Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization and Documentation

Prior authorization is required for prosthetic items that exceed the plan-specific dollar thresholds and for certain devices per the Durable Medical Equipment, Prosthetics and Orthotics guidance. Submit a prior authorization request demonstrating medical necessity and include all supporting documentation.

Preauthorization thresholds: most commercial plans: > $1,000; Medicaid/Healthy Michigan Plan: > $500
Follow Priority Health prior authorization guidance and provider manual DME/Prosthetics guidance for submission instructions

Billing Rule

Use Exact HCPCS Code for Advanced Components

Use the exact HCPCS (L‑code) when billing for advanced or powered components. Advanced components listed (including microprocessor or powered features) require the specific HCPCS code shown in the prosthetics code list.

Examples: L5856, L5857, L5858, L5859 (microprocessor/powered knee features); L5969, L5973 (power‑assist/microprocessor ankle/foot features)
Do not substitute generic or unlisted codes when a specific L‑code exists

Note

Diagnosis‑Limited Coverage — Consult LCD

Some HCPCS/L‑codes are covered only for specific diagnoses or per Medicare Local Coverage Determinations (LCDs). Consult the applicable LCD for Medicare members to confirm diagnosis limitations and coverage criteria before billing.

When a code is listed as diagnosis‑limited, include the supporting ICD‑10 diagnosis on the claim and retain clinical documentation
Refer to the applicable Medicare LCD for code‑level coverage rules

Denial Risk

Modifier‑Related Denials

Certain modifier usage is required and failure to append required modifiers will result in denials. Append the KX modifier to indicate policy criteria have been met; for Medicare claims use required CMS modifiers per the LCD.

KX modifier: must be appended where indicated; claims reported without KX will deny as non‑payable (Commercial, Medicaid)
Medicare: use KX, GA, GY, or GZ as specified by the applicable LCD

Denial Risk

Denial Triggers from Not Covered List

Some codes are explicitly not covered and will trigger claim denials when billed. Verify the Not Covered list before submitting claims.

Example Not Covered items: A9282 (wigs), E3200 (gait modulation system), L8035 (custom breast prosthesis, post mastectomy)
Claims for items on the Not Covered list will be denied

Denial Risk

Explicit Not Covered Code

L5991 is explicitly marked not covered and should not be billed for any lines of business.

Do not submit L5991 — it is not covered

Billing Rule

Billing Requires Matching HCPCS L‑Code

Billing must match the specific HCPCS L‑code that describes the socket, insert, suspension, addition, repair, or accessory provided. Submit repair codes with itemized notes describing work completed.

Include the exact L‑code for sockets (e.g., L5510–L5595 series), inserts (L5644–L5686 series), suspensions, additions (L5610‑L5969 series), and repair codes (L7510, L7520)
Repair claims: attach notes itemizing the work completed

Documentation Required

Unlisted Code Documentation

Claims billed with unlisted L‑codes must include explanatory documentation describing the item or service, justification, and specification of why a specific L‑code does not apply.

Unlisted codes requiring explanatory notes: L5999, L7499, L8499, L8699, L9900
Provide detailed description, clinical rationale, and any supporting photos or manufacturer documentation when applicable

Key Definitions

Prosthetic device — definition

DefinitionAn artificial device worn temporarily or permanently that replaces all or part of the functions of a body part (e.g., limb or eye prosthesis).

Coverage triggerCovered when needed to restore function to a permanently inoperative, malfunctioning, or absent body part; permanence indicated by ordering physician.

ExamplesIncludes standard external prosthetic devices (sockets, inserts, terminal devices) described by HCPCS L‑codes

Osseointegrated prosthesis (OP) — definition and examples

DefinitionBone‑anchored lower limb prosthetic system that attaches directly to bone without use of a socket (osseointegration).

Example systemOPRA Implant System (Integrum Inc.) — FDA PMA approved December 18, 2020, product code PJY; two‑stage surgical implantation described in policy.

Policy stanceOsseointegrated/osseoanchored lower limb prosthetic devices are considered experimental, investigational, or unproven and are not medically necessary (not covered).

Preparatory socket — definition and code examples

DefinitionPreparatory sockets are temporary or early‑fitting sockets used during rehabilitation/initial fitting (codes L5510–L5595 examples).

Example codesL5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585 (preparatory below/above knee sockets).

Use caseUsed for initial fitting and adjustment prior to provision of definitive prosthetic sockets.

Socket insert — definition and example materials

DefinitionSocket inserts are internal cushioning/volume‑management components placed inside the prosthetic socket to improve fit and comfort.

Example materialsKemblo, Pelite, Aliplast, Plastazote, silicone gel, elastomeric materials; see codes L5654–L5666, L5673, L5679, L6691–L6697 for specifics.

Clinical roleUsed for limb volume management, pressure distribution, and suspension interface between residuum and socket.

L-codes — HCPCS Level II codes used to describe prosthetic components

DefinitionHCPCS Level II L‑codes are procedure codes used to describe prosthetic components and external prosthetic devices (sockets, inserts, additions, terminal devices, etc.).

Scope examplesRanges include lower extremity L5xxx series (sockets, additions), advanced features (L5856–L5859), and upper extremity additions/components (L6647–L6975).

Billing requirementProviders must submit claims using the exact L‑code that matches the described prosthetic component.

Unlisted L-codes — require explanatory notes with claims

RequirementClaims billed with unlisted L‑codes (e.g., L5999, L7499, L8499, L8699, L9900) must include explanatory notes to describe the item/service, reason for using an unlisted code, and clinical justification.

Example unlisted codesL5999 (Lower extremity prosthesis, NOS); L7499 (Upper extremity prosthesis, NOS); L8499; L8699; L9900.

Documentation purposeExplanatory documentation allows medical review to determine medical necessity and appropriate reimbursement for items not captured by specific L‑codes.

OpenPayer

PROSTHETICS - EXTERNAL

Coverage and Medical Necessity

HCPCS / CPT / ICD-10 Codes

Billing, Authorization, and Documentation Requirements

Policy Background

Key Definitions