ModifiedUnitedHealthcarePolicy CSNCT0361.04

Lower Extremity Prosthetics (for North Carolina Only)

Policy governing coverage and coding references for lower extremity prosthetic devices and related services for UnitedHealthcare members in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Prosthetics (for North Carolina Only)

Policy CodePolicy CSNCT0361.04

Change TypeHCPCS list updatematerial

Effective Date05/01/2025

Next Review DateN/A

Key ActionUse the updated HCPCS list (including added L5827) when requesting prior authorization or submitting claims.

SourceLink

POLICY UPDATE CHANGES

Applicable HCPCS codes updated to reflect quarterly edits; added L5827 and archived previous policy version CSNCT0361.03.

~200+HCPCS L-codes listed or referenced

~60+HCPCS codes for lower extremity

05/01/2025Current revision effective

NCApplicable state

Coverage and Medical Necessity Criteria

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Medical necessity delegation

Covered when the referenced North Carolina Medicaid clinical coverage policy criteria are met:

Medical necessity delegation: Coverage and medical necessity clinical criteria for prosthetic devices and for servicing and repairing orthotic and prosthetic devices are governed by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy: Medical Equipment: SB, Orthotics & Prosthetics.

Implantable devices or prostheses that are surgical in nature, such as artificial heart valves, are not considered prosthetics under this policy. If these implantable devices are covered, they would be handled and billed as surgical services, not under the prosthetics benefit.

Some HCPCS codes in the listing are marked with an asterisk. Codes labeled with an asterisk are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Providers should verify state fee schedule status before submitting claims or requesting prior authorization.

HCPCS / Coding References

Applicable HCPCS L-codes (sample)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.

Related HCPCS L-codes (continued listings)HCPCS

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.
L5210	Above knee (AK), short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each.
L5301	Below knee (BK), molded socket, shin, SACH foot; endoskeletal system.
L5615	Addition; endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control.
L5827	Endoskeletal knee-shin system, single axis, electromechanical and stance phase control, with or without shock absorption and stance extension damping swing.
L5856	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s).
L5910	Addition, endoskeletal system, below knee (BK), alignable system.

Applicable HCPCS CodesHCPCS

L5826	Addition, endoskeletal knee-shin system, single axis, fluid swing phase control
L5827	Endoskeletal knee-shin system, single axis, electromechanical and stance phase control, with or without shock absorption and stance extension damping swing
L5828	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
L5830	Addition, endoskeletal knee-shin system, single axis, pneumatic swing phase control
L5840	Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable
L5848	Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability
L5850	Addition, endoskeletal system, above knee (AK) or hip disarticulation, knee extension assist
L5855	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist
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.

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inv-07: FDA device classification — class notes and OPRA PMA

FDA device class for most prosthetic componentsMost prosthetic devices and components are classified by the FDA as Class I medical devices (lowest regulatory control); manufacturers are generally exempt from premarket notification and are not required to provide safety and effectiveness data prior to marketing.

OPRA TM Implant System regulatory statusThe OPRA Implant System (Osseoanchored Prostheses for the Rehabilitation of Amputees) was granted FDA premarket approval (PMA) on December 18, 2020.

Purpose of FDA section in policyThis FDA information is for informational purposes only; FDA approval alone is not a basis for coverage under this policy.

Examples of Class I prosthetic componentsExamples include ankle components, cables, and prosthesis suction valves (devices typically exempt from premarket notification).

Provider Billing, Authorization, and Documentation Actions

Prior Authorization

Prior Authorization / Provider Alert

Prior authorization may be required for certain prosthetic devices. Providers should verify authorization and plan-specific requirements prior to delivery of services to avoid claim denials. Also confirm any applicable state or contractual mandates that supersede this policy.

Prior authorization: check member's benefit plan and state-specific rules
Verify any North Carolina Medicaid-specific authorization requirements

Billing Rule

Updated HCPCS / Billing Impact

Updated HCPCS: The list of applicable HCPCS/L-codes in this policy was updated to reflect quarterly edits and the addition of L5827. Providers should confirm coding and prior authorization impacts when billing.

Added HCPCS code L5827
Review billing impact for other listed L-codes

Note

Reference: NC Medicaid Clinical Coverage Policy

For medical necessity clinical coverage criteria and sequencing guidance, providers should refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy: Medical Equipment: SB, Orthotics & Prosthetics.

Use NC Medicaid Clinical Coverage Policy for medical necessity sequencing

Denial Risk

Code Listing Caveat

Listing a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws. Inclusion of a code does not guarantee reimbursement or payment.

A listed code is for reference only and is not a coverage determination
Coverage and payment are subject to applicable federal, state, or contractual requirements

Documentation Required

Documentation Requirements

Providers should document the specific HCPCS/L-code(s) billed and the clinical indication supporting medical necessity in the medical record. Adequate documentation should be retained to support claims and prior authorization requests.

Document specific HCPCS/L-code(s) and clinical indication
Retain supporting medical records for claims and authorizations

Note

Coverage Decision Authority

Coverage decision authority: Benefit coverage for health services is determined by federal, state, or contractual requirements. In the event of a conflict, federal, state, or contractual requirements govern over this policy. Always check the member's plan and applicable laws before rendering services.

Federal, state, or contractual requirements govern coverage decisions
Check member-specific plan documents and state mandates

Billing Rule

State Fee Schedule Exclusions (NC)

Codes labeled with an asterisk in the related codes list are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid. Providers should verify state fee schedule applicability before billing.

Asterisked codes may not be on NC Medicaid Fee Schedule
Confirm coverage with NC Medicaid prior to billing

Definitions and Background

This UnitedHealthcare policy delegates medical necessity clinical criteria for prosthetic devices and for servicing and repairing orthotic and prosthetic devices to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy: Medical Equipment — Orthotics & Prosthetics. Providers should refer to that North Carolina Medicaid clinical coverage policy for detailed medical necessity rules, including any sequencing or device-specific criteria that govern coverage decisions.

The policy also clarifies that certain devices, specifically surgical implantable prostheses (for example, artificial heart valves), are excluded from prosthetics classification and, when applicable, are to be managed as surgical services under the applicable clinical and billing rules.

inv-17: Definitions — Implantable devices/prostheses classification note

Classification note (implantable devices)Implantable devices/prostheses that are surgical in nature (for example, artificial heart valves) are not considered prosthetics under this policy and, if covered, would be handled as surgical services.

Policy implicationSuch implantable surgical prostheses are excluded from prosthetics coverage and follow surgical coverage processes when covered.

Reference guidanceRefer to the policy's Indications for Coverage section for the classification distinction between implantable surgical devices and prosthetics.

inv-18: Definitions — Prosthesis definition

Prosthesis definitionA prosthesis is an artificial device used to replace all or part of a missing body part and is intended to restore normal function.

Functional goalIntended to restore activities such as ambulation on level and uneven surfaces, stairs, ramps, curbs, independent dressing, and return to work with or without modifications.

Typical anatomic scopeDefinition and examples focus on lower limb prostheses and common amputation levels (e.g., transtibial), as referenced in clinical context.

inv-19: Definitions — OPRA implant description and FDA PMA

OPRA Implant descriptionThe OPRA TM Implant System is an osseo‑anchored prosthesis system composed of parts that allow a prosthesis to attach directly to the femur (thigh bone).

Regulatory milestoneThe OPRA system received U.S. FDA premarket approval (PMA) on December 18, 2020.

Informational noteFDA information provided in the policy is informational only and does not by itself determine coverage decisions.

OpenPayer

Lower Extremity Prosthetics (for North Carolina Only)

Coverage and Medical Necessity Criteria

HCPCS / Coding References

Provider Billing, Authorization, and Documentation Actions

Definitions and Background

Policy Revisions and Effective Dates