DraftUnitedHealthcarePolicy CS361ID.D

Lower Extremity Prosthetics (for Idaho Only)

This policy governs medical necessity and coding guidance for lower extremity prosthetic devices and related services for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Prosthetics (for Idaho Only)

Policy CodePolicy CS361ID.D

Change TypeMaterial updates to HCPCS code list and code descriptions

Effective Date06/01/2026

Next Review Date

Key ActionRefer to the Idaho Medicaid Provider Handbook and DME MAC LCD L33787 for medical necessity criteria and obtain required documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS code L5657 to the Applicable Codes list.

Revised descriptions for HCPCS codes L5673 and L5679.

Updated References section to reflect the most current information.

Archived previous policy version CS361ID.C.

100+HCPCS L-codes listed

~70+Lower extremity codes in section

IdahoState-specific applicability

Class IFDA classification noted

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Coverage Criteria and Determinations

General Coverage Determination

Coverage is determined by referenced external clinical criteria.

Referenced criteria must be met: Medical necessity for lower extremity prosthetics is determined by the Idaho Medicaid Provider Handbook: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies — Covered Services and Limitations: Prosthetics and Orthotics, and, where not addressed, by the DME MAC Local Coverage Determination for Lower Limb Prostheses (L33787).

Provider must follow those documents for specific clinical criteria and prior authorization requirements.

The following information clarifies how procedure and diagnosis codes are used in this policy. Listing of 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 applicable federal, state, or contractual requirements and laws, which may mandate coverage for a specific service despite the code listing.

Information about U.S. Food and Drug Administration (FDA) status is provided for context only. FDA approval alone is not a basis for coverage. FDA classification and premarket approvals are informational and do not replace the medical necessity criteria referenced elsewhere in this policy.

The code lists in this policy are provided for reference and may not be exhaustive. The inclusion of a code does not imply any right to reimbursement or guarantee payment of a claim. Coverage and payment decisions are subject to the medical necessity criteria, documentation requirements, and any other applicable policies or contractual provisions.

Applicable Codes and Regulatory Notes

Code list contextHCPCS

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 (SACH).
L5100	Below knee (BK), molded socket, shin, SACH foot.

Applicable HCPCS L-codes (selection)HCPCS

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 (SACH).
L5100	Below knee (BK), molded socket, shin, SACH foot.

Remaining Applicable HCPCS L-codesHCPCS

L5110-L5970

Continuation of lower extremity prosthetic HCPCS L-code series as listed in the policy (includes BK/AK sockets, test sockets, additions, replacements, microprocessor knees, power assist, ultra-light materials, etc.).

Applicable knee-shin system additionsHCPCS

L5826	Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame.
L5827	Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping.
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, four-bar linkage or multiaxial, pneumatic swing phase control.
L5845	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.

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Endoskeletal system additions and foot components (part 1)HCPCS

L5910	Addition, endoskeletal system, below knee (BK), alignable system.
L5920	Addition, endoskeletal system, above knee (AK) or hip disarticulation, alignable system.
L5925	Addition, endoskeletal system, above knee (AK), knee disarticulation or hip disarticulation, manual lock.
L5926	Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type.
L5930	Addition, endoskeletal system, high activity knee control frame.
L5940	Addition, endoskeletal system, below knee (BK), ultra-light material (titanium, carbon fiber or equal).
L5950	Addition, endoskeletal system, above knee (AK), ultra-light material (titanium, carbon fiber or equal).
L5960	Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal).
L5961	Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control.
L5962	Addition, endoskeletal system, below knee (BK), flexible protective outer surface covering system.

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Foot component codes (part 2)HCPCS

L5971	All lower extremity prostheses, solid ankle cushion heel (SACH) foot, replacement only.
L5972	All lower extremity prostheses, foot, flexible keel.
L5973	Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source.
L5974	All lower extremity prostheses, foot, single axis ankle/foot.
L5975	All lower extremity prostheses, combination single axis ankle and flexible keel foot.
L5976	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal).
L5978	All lower extremity prostheses, foot, multiaxial ankle/foot.
L5979	All lower extremity prostheses, multiaxial ankle, dynamic response foot, one-piece system.

Miscellaneous prosthetic components, consumables, and accessoriesHCPCS

L5980	All lower extremity prostheses, flex-foot system.
L5981	All lower extremity prostheses, flex-walk system or equal.
L5982	All exoskeletal lower extremity prostheses, axial rotation unit.
L5984	All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability.
L5985	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon.
L5986	All lower extremity prostheses, multiaxial rotation unit (MCP or equal).
L5987	All lower extremity prostheses, shank foot system with vertical loading pylon.
L5988	Addition to lower limb prosthesis, vertical shock reducing pylon feature.
L5990	Addition to lower extremity prosthesis, user adjustable heel height.
L5991	Addition to lower extremity prostheses, osseointegrated external prosthetic connector.

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FDA classification (informational)

FDA device classClass I — prosthetic devices and components are classified by the FDA as Class I (general controls; often exempt from premarket notification).

Regulatory implicationClass I devices have the least regulatory control; manufacturers are generally exempt from premarket notification and are not required to provide premarketing safety/effectiveness data.

Examples citedExamples include ankle, foot, hip, knee, and socket components; mechanical or powered hand, hook, wrist unit, elbow joint, and shoulder joint components; cable and prosthesis suction valves.

Coverage noteFDA approval or classification is informational only; FDA approval alone is not a basis for coverage determinations under this policy.

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization: Check Plan Requirements

Prior authorization requirements vary by member plan and may be required by federal, state, or contractual benefit provisions. Before rendering services or submitting claims, verify whether prior authorization is required for lower extremity prosthetics under the member's benefit plan and obtain any required approvals.

Check the member’s specific benefit plan and applicable federal/state/contractual requirements for prior authorization rules
If required, submit prior authorization with supporting documentation per plan procedures

Denial Risk

Documentation-Related Denials

The patient's medical record must contain documentation that fully supports the medical necessity for the requested prosthetic services. Lack of adequate or legible documentation may result in denial of the request or claim.

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures

Background and Policy References

This policy relies on external clinical coverage criteria when determining medical necessity for lower extremity prosthetic devices. Providers must follow the Idaho Medicaid Provider Handbook: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies and, where not addressed, the DME MAC Local Coverage Determination for Lower Limb Prostheses (LCD L33787). Additionally, FDA information is provided for context only; for example, prosthetic components are generally classed by the FDA as Class I devices, but that classification alone does not establish coverage.

Definitions and Device Notes

Partial foot prosthesis (selected HCPCS L-codes)

L5000Partial foot, shoe insert with longitudinal arch, toe filler.

L5010Partial foot, molded socket, ankle height, with toe filler.

L5020Partial foot, molded socket, tibial tubercle height, with toe filler.

L5050Ankle, Symes, molded socket, SACH foot.

L5060Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot (SACH).

L5100Below knee (BK), molded socket, shin, SACH foot.

OPRA Implant System (osseointegration PMA)

Policy Revision History

2026-06-01material_changeLatest

Added HCPCS code L5657 to the Applicable Codes list and revised descriptions for HCPCS codes L5673 and L5679.