CurrentUnitedHealthcarePolicy CSNCT0361.05

Lower Extremity Prosthetics (for North Carolina Only)

UnitedHealthcare Medical Policy for lower extremity prosthetic devices and associated services applicable only to North Carolina members; aligns coverage decisions with North Carolina Medicaid Clinical Coverage Policy 5B and federal/state/contractual requirements. Includes applicable HCPCS L-codes, documentation requirements, and references to repair/servicing and implantable device distinction.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Prosthetics (for North Carolina Only)

Policy CodePolicy CSNCT0361.05

Change TypeAdded documentation language; HCPCS edits

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must maintain legible medical records including relevant medical history, physical exam, and pertinent diagnostic test results to substantiate medical necessity; records must be available upon request.

SourceLink

POLICY UPDATE CHANGES

Added detailed medical records documentation language to 'Medical Records Documentation Used for Reviews' section.

Updated list of applicable HCPCS codes to reflect quarterly edits: added L5657 and revised descriptions for L5673 and L5679.

~200HCPCS codes listed

1State applicability

1Policy effective date

Overview: UnitedHealthcare Medical Policy CSNCT0361.05 - Lower Extremity Prosthetics (North Carolina). Scope: policy applies only to North Carolina and aligns coverage decisions with the North Carolina Medicaid Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics. Coverage stance: mixed (inclusion of codes and services in the policy does not guarantee reimbursement; coverage is determined by federal, state, or contractual requirements). Effective/last review date: March 1, 2026.

Policy Metadata

Policy NumberCSNCT0361.05

Policy TitleLower Extremity Prosthetics (North Carolina)

PayerUnitedHealthcare

Geographic ScopeNorth Carolina

Effective Date2026-03-01

Last Review Date2026-03-01

StatusCURRENT

Medical Necessity / Coverage Criteria

General Coverage / Medical Necessity

Coverage is determined per federal, state, or contractual requirements and the North Carolina Medicaid Clinical Coverage Policy: Medical Equipment: 5B, Orthotics & Prosthetics. Medical records documentation is required to support medical necessity.

ALL of the following

Service compliance: Service must comply with applicable federal, state, or contractual requirements and laws that may require coverage for a specific service.
Clinical criteria reference: Member must meet medical necessity clinical coverage criteria as defined in North Carolina Medicaid Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics.
Medical records documentation: Patient medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Records availability: Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Implantable Devices

Distinction for implantable devices/prostheses

Implantable device distinction: Implantable devices/prostheses (e.g., artificial heart valves, OPRA implant system) are not considered prosthetics under this policy and, if covered, are covered as a surgical service.

Servicing and Repair

Servicing/repair coverage reference

Servicing and repair reference: Medical necessity clinical coverage criteria for servicing and repairing orthotic and prosthetic devices refer to the North Carolina Medicaid Clinical Coverage Policy, Medical Equipment: 5B, Orthotics & Prosthetics.

Definitions & Background

Background: A prosthesis is defined as an artificial device used to replace all or part of a missing body part and intended to restore normal function. Common lower-limb amputation levels include the transtibial (transtibial/BK, below knee) and transfemoral (transfemoral/AK, above knee). Functional goals for lower limb prostheses include ambulation on level and uneven surfaces, negotiating stairs/ramps/curbs, independence with dressing, and return to work with or without modifications. The policy directs reviewers to the North Carolina Medicaid Clinical Coverage Policy 5B for medical necessity criteria. FDA classification: most prosthetic devices and components are Class I medical devices (exempt from premarket notification) and the OPRA implant system is noted separately as an FDA-approved implantable osseointegration device (PMA) that, if covered, would be addressed as a surgical implant rather than a prosthetic under this policy.

Prosthesis: An artificial device used to replace all or part of a missing body part and intended to restore normal function.

Applicable HCPCS Codes

Applicable HCPCS L-codes (prosthetics/components/additions/replacements/repairs)HCPCS

L5000	Partial foot, shoe insert with longitudinal arch, toe filler.
L5010	Partial foot, molded socket, ankle height, with toe filler.
L5050	Ankle, Symes, molded socket, sach foot.
L5060	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot (SACH).
L5100	Below knee (BK), molded socket, shin, SACH foot.
L5105	Below knee (BK), 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.
L5200	Above knee (AK), molded socket, single axis constant friction knee, shin, sach foot.
L5210	Above knee (AK), short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each.

1–10 of 197

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HCPCS codes not on State of North Carolina Medicaid Fee Schedule (may not be covered by NC Medicaid)HCPCS

L5657	Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials. (Not on NC Medicaid Fee Schedule)
L5510	Preparatory, below knee (BK) PTB type socket... (marked with *)
L5615	Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control. (marked with *)
L5617	Addition to lower extremity, quick change self-aligning unit... (marked with *)
L5632	Addition to lower extremity, Symes type, 'ptb' brim design socket. (marked with *)
L5637	Addition to lower extremity, below knee (BK), total contact. (marked with *)
L5661	Addition to lower extremity, socket insert, multidurometer Symes. (marked with *)
L5665	Addition to lower extremity, socket insert, multidurometer, below knee (BK). (marked with *)
L5699	All lower extremity prostheses, shoulder harness. (marked with *)
L5827	Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control... (marked with *)

1–10 of 22

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Provider Actions & Billing Impact

Documentation Required

Medical records must support medical necessity

Providers must maintain legible medical records including relevant medical history, physical exam, and pertinent diagnostic test results to substantiate medical necessity; records must be available upon request.

Documentation must fully support medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation must be legible, maintained in the patient’s medical record, and made available upon request.
Policy language was added clarifying that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required to assess clinical criteria but does not guarantee coverage.

Billing Rule

Use applicable HCPCS L-codes

Providers must report services using the applicable HCPCS L-codes listed in the policy; inclusion of a code does not guarantee reimbursement and other policies may apply.

All HCPCS L-codes listed in code_groups

Denial Risk

State fee schedule exceptions

Some HCPCS codes (marked with an asterisk) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid; claims may be denied if a code is not on the fee schedule.

L5657
L5510
L5615
L5632
L5637
L5661
L5665
L5699
L5827
L5856
L5857
L5858
L5859
L5925
L5969
L5973
L5990
L7367

Not Covered / Experimental & Fee Schedule Exceptions

Coverage stance summary: The policy stance is mixed. Inclusion of a HCPCS code in the policy is for reference only and does not guarantee reimbursement or claim payment; benefit coverage is determined by federal, state, or contractual requirements and applicable laws. Geographic limitation: this policy only applies to the state of North Carolina. Some HCPCS L-codes listed in the policy are explicitly noted as not on the State of North Carolina Medicaid Fee Schedule (codes marked with an asterisk, e.g., L5657 and others), and therefore may not be covered by NC Medicaid.

Revision History

03/01/2026addedLatest

Added detailed medical records documentation language to 'Medical Records Documentation Used for Reviews' section.

03/01/2026revisedLatest

Updated list of applicable HCPCS codes to reflect quarterly edits: added L5657 and revised descriptions for L5673 and L5679; added notation that L5657 is not on NC Medicaid Fee Schedule.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Prosthetics (for North Carolina Only)

Policy CodePolicy CSNCT0361.05

Change TypeAdded documentation language; HCPCS edits

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

OpenPayer

Lower Extremity Prosthetics (for North Carolina Only)

Coverage Summary

Medical Necessity / Coverage Criteria

Definitions & Background

Applicable HCPCS Codes

Provider Actions & Billing Impact

Not Covered / Experimental & Fee Schedule Exceptions

Revision History