CurrentWPS Health InsurancePolicy PUM 250-0026-1709

Durable Medical Equipment (DME)-Upper and Lower Limb Prostheses Medical Guideline

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This guideline governs medical necessity, coverage criteria, coding, documentation, repairs, replacements, supplies, and limitations for durable upper- and lower-limb prosthetic devices and related components. Coverage varies by member benefit plan.

Policy Summary

PayerWPS Health Insurance

PolicyDurable Medical Equipment (DME)-Upper and Lower Limb Prostheses Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with the complete prosthetic system, required Standard Written Order, and supporting medical-necessity records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsPrescription-to-provision interval

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CurrentWPS Health InsurancePolicy PUM 250-0026-1709

Durable Medical Equipment (DME)-Upper and Lower Limb Prostheses Medical Guideline

Customize your policy alerts

Sign up for WPS Health Insurance Policy PUM 250-0026-1709 alerts

Get alerted when Policy PUM 250-0026-1709 changes without checking for updates manually.

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Policy Summary

PayerWPS Health Insurance

PolicyDurable Medical Equipment (DME)-Upper and Lower Limb Prostheses Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with the complete prosthetic system, required Standard Written Order, and supporting medical-necessity records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsPrescription-to-provision interval

Functional level for specified advanced devices

>400 ydDaily ambulation threshold

3 monthsStandard prosthesis trial

3 yearsReplacement interval

2Test sockets per prosthesis

Medical Necessity and Coverage Criteria

General prosthetic device criteria

Covered when ALL of the following criteria are met:

Care is prescribed by a physician, nurse practitioner, podiatrist, or other health professional qualified under state law to prescribe prosthetics.
The prosthesis will significantly improve or restore physical functions required for mobility-related activities of daily living.
The participating physician or licensed health care practitioner has determined, based on physical examination, that the prosthesis will allow the member to perform activities of daily living.
The prosthesis is provided within six months of the prescription date.within 6 months of prescription
Prosthetic services are performed by a duly licensed or certified prosthetic provider, with all services within the provider's applicable scope of practice.
The services are of a complexity and nature requiring a licensed or certified professional prosthetist, or are provided under the prosthetist's direct supervision by permitted ancillary personnel.
The certified professional prosthetist is in good standing with the American Board for Certification, the Board of Certification/Accreditation, or the state licensing authority where legally required.

Mechanical lower-limb prosthesis

Covered when the general prosthetic device criteria are met AND the applicable functional-level requirement is satisfied:

All general prosthetic device criteria are met.
A single-axis, fluid swing and stance phase control lower-limb addition is requested for an individual at functional level 3 or greater.functional level 3 or greater
Applies to HCPCS L5828.

Microprocessor-controlled lower-limb prostheses

Covered when ALL applicable criteria are met and one covered device-specific pathway applies:

Microprocessor-controlled lower-limb prosthesis

All general prosthetic device criteria are met.
The individual is at functional level 3 or greater when required, and the device and its required components are consistent with the individual's functional level.functional level 3 or greater when required
ONE covered device-specific pathway
- Microprocessor ankle-foot prosthesis
  - An ankle-foot prosthesis is requested for a transtibial amputee.
    Applies to HCPCS L5973.
- Microprocessor knee prosthesis

Powered lower-limb prosthesis

Covered when ALL of the following criteria are met:

Powered lower-limb prosthetic device

The individual has a swing- and stance-phase microprocessor-controlled electronic knee, such as HCPCS L5856.
The individual is functional level 3 (K3) only.K3 only
The individual has a documented spine or sound-limb comorbidity affecting hip extension or quadriceps function that impairs K3-level function when using the microprocessor-controlled knee alone.
The device is not requested for high-impact activity, sports, excessive loading, or heavy-duty use.
Applies to HCPCS L5859.

Advanced lower-limb device utilization

Covered when ALL of the following utilization criteria are met:

Advanced lower-limb technology utilization

The individual is willing to ambulate.
The individual's current daily activities exceed the capabilities of a standard lower-limb prosthesis.
The individual has used a standard lower-limb prosthesis for independent daily activities for at least three months.minimum 3 months
Medical, physical therapy, and prosthetist records show that the device will enable the individual to reach at least functional level 3 within three months of obtaining it.functional level 3 within 3 months

Upper-limb myoelectric prosthesis

Covered when ALL of the following criteria are met:

The individual has an amputation or congenital absence involving part of an arm.
All general prosthetic device criteria are met.
A standard body-powered prosthesis is insufficient for activities of daily living or cannot be used.
The individual is at least 2 years old.age 2 years or greater
The individual has unilateral transradial or transhumeral deficiency, and the remaining proximal-arm musculature contains the minimum microvolt threshold needed to operate a myoelectric prosthesis.

Supplies, accessories, sockets, and liners

Covered when used with an approved prosthetic device and medically necessary:

Supplies and accessories are medically necessary for the effective functioning of allowed equipment.
Repairs or adjustments are needed because of bone growth, reasonable weight loss or gain, or normal wear and tear during normal use.
A medically necessary prosthesis requires replacement because repairs or adjustments have failed or are not possible.
Up to two diagnostic test sockets are provided for an individual prosthesis.up to 2 test sockets per prosthesis
Prosthetic sheaths or socks, including a gel cushion layer, are medically necessary.

Fitness and specialty-sports prosthetics are not medically necessary when microprocessor-controlled or powered lower-limb prosthetics or accessories are designed for activities other than normal daily living, such as specialty sports or fitness participation. Examples include the Ottobock above-knee X-3 waterproof prosthesis, Moto Knee, and Sprinte foot; plan-specific exclusions may also apply.

The guideline excludes or classifies various technologies as experimental, investigational, and unproven, including microprocessor-controlled ankle-foot prostheses for certain indications, myoelectric lower-limb prostheses, implantable upper-limb myoelectric sensors, partial-finger devices, lower-body exoskeletons for spinal cord injury, osseointegrated prostheses, vacuum-assisted socket systems, selected robotic arms and orthoses, and robotic rehabilitation.

The JACO assistive robotic arm, a wheelchair-mounted assistive device, is not medically necessary because it is considered a personal convenience item.

Use of a microprocessor-controlled prosthesis instead of a standard prosthesis is not medically necessary for home use or for a limited community ambulator, including use for activities such as climbing stairs in the home or at work.

A microprocessor-controlled lower-limb prosthesis is not medically necessary for indications other than the covered device-specific pathways described in the guideline. Requests outside those indications are considered experimental, investigational, and unproven; requests for listed indications that do not meet the applicable criteria are not medically necessary.

A powered microprocessor-controlled ankle-foot prosthesis with power assist is not medically necessary. Examples include the PowerFoot BiOM, iWalk, Proprio Foot, and Empower Ankle. The listed HCPCS codes are L5973 and L5969. Powered lower-limb prosthetics requested for other indications are also not medically necessary when the applicable criteria are not met.

A microprocessor-controlled lower-limb prosthesis is not medically necessary when the member's functional needs can be met by a standard non-electronic prosthesis. A knee microprocessor is also not medically necessary when the member's functional level is below K3.

The Genium3x lower-limb prosthesis and other special-feature or nonstandard models are not medically necessary when additional features have not been demonstrated to be superior to a standard device or when the model is not the lowest-cost alternative that meets the member's rehabilitation needs.

The Kenevo microprocessor knee designed for K2 walkers is considered experimental, investigational, and unproven to affect health outcomes.

Unless the health plan specifies otherwise, replacement of a prosthesis within less than three years of purchase is generally not medically necessary unless all applicable Indications of Coverage criteria are met.

Replacement of a prosthetic limb or its parts is not medically necessary when repair would cost less than replacement. Repair-versus-replacement decisions remain subject to the applicable repair and replacement criteria.

Covered Codes and Utilization Limits

Covered lower-limb mechanical prosthetic additionHCPCSCovered

L5828

Single axis, fluid swing and stance phase control lower limb addition

Covered microprocessor-controlled lower-limb prosthetics when criteria are metHCPCSCovered

L5973	Ankle-foot prosthetic
L5856	Knee prosthetic
L5857	Knee prosthetic
L5858	Knee prosthetic

Covered powered lower-limb prosthetic when criteria are metHCPCSCovered

L5859

Endoskeletal knee-shin system with powered and programmable flexion/extension assist control

Not medically necessary powered ankle-foot prostheticsHCPCSNot Covered

L5973	Microprocessor-controlled ankle-foot prosthetic with power assist
L5969	Microprocessor-controlled ankle-foot prosthetic with power assist

Daily long-distance ambulation

ThresholdGreater than 400 yards

Ambulation patternDaily long-distance ambulation at variable rates

Additional activityRegular ambulation on uneven terrain or regular use of stairs

Standard prosthesis use before advanced device

Minimum trial period3 months

Required deviceStandard lower-limb prosthesis

Authorization and Documentation Requirements

Prior Authorization

Specify the Complete Prosthetic System

Identify the complete prosthetic system in both the prescription and prior authorization request, including the base prosthesis and every component required for effective use.

Specify microprocessor motors, external battery packs, and all other parts that will be used.
Identify applicable components, including the socket, suspension mechanism, joint, pylon, and terminal device (such as a foot or hand).

Documentation Required

Use Qualified Prescribers and Providers

Ensure care is prescribed by a practitioner qualified under State law and that the prosthesis is provided within six months of the prescription. Services must be performed by a duly licensed or certified provider within the applicable scope of practice and at the required professional level.

Qualified prescribers include a physician, nurse practitioner, podiatrist, or other health professional qualified to prescribe prosthetics under State law.

Policy Background

Prostheses replace missing body parts, and device selection depends on the amputation level, physical condition, ability to ambulate safely, expected activity level, and plan coverage. Lower-limb medical necessity is assessed using functional levels from K0 through K4, ranging from inability to ambulate safely to high-impact or athletic use. Microprocessor-controlled and myoelectric technologies are higher-complexity options that require documentation of functional need, rehabilitation potential, and the ability to use the technology safely.

Functional Levels and Prosthetic Device Definition

Functional level 0

Functional level0

AbilityDoes not have the ability or potential to ambulate or transfer safely with or without assistance

Prosthetic benefitThe prosthesis does not enhance quality of life or mobility

Functional level 1

Functional level1

AbilityHas the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence

Typical classification

Policy Summary

PayerWPS Health Insurance

PolicyDurable Medical Equipment (DME)-Upper and Lower Limb Prostheses Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with the complete prosthetic system, required Standard Written Order, and supporting medical-necessity records.

SourceLink

On This Page

The individual has a knee disarticulation or transfemoral amputation.
The individual needs daily long-distance ambulation at variable rates greater than 400 yards.>400 yards daily
The individual regularly ambulates on uneven terrain or uses stairs.
The individual has adequate cardiovascular, neuromuscular, and pulmonary reserve for ambulating at a faster-than-baseline rate.
The individual demonstrates the ability to ambulate at a faster-than-baseline rate using a standard prosthesis with a swing- and stance-control knee.
The individual has the cognitive ability to master gait sequencing and care requirements for the higher level of technology.
The individual is at functional level 3 or 4.functional level 3 or 4
Applies to HCPCS L5856, L5857, and L5858.

Combination prosthetic system

A microprocessor-controlled knee alone is inadequate to meet functional needs, such as because of continued knee or foot instability caused by environmental or anatomical barriers.

Complex sensory microprocessor device

The individual is an above-knee or knee-disarticulation amputee.
All general prosthetic device criteria are met.
Extensive prosthetist evaluation supports functional level K3 or higher.at least K3
Documentation identifies specific activities or difficulties with the current prosthesis that can be addressed by the new prosthesis.

Records document the current and expected functional levels and explain why the expected functional level cannot be achieved with the current prosthesis.

No significant cardiovascular, musculoskeletal, pulmonary, or neuromuscular condition prohibits maximal use of the device.

Gait analysis documents that the individual can ambulate faster than with the standard prosthesis despite appropriate adjustments to the current prosthesis.

The individual's weight and height are appropriate for the selected device.

The individual has the cognitive ability to operate the myoelectric prosthesis and participate in prosthetic training.

The individual can tolerate the weight of the prosthesis.

The individual does not have an underlying neuromuscular disease.

12 prosthetic gel stockings in 12 months

No more than two socket inserts are provided per individual prosthesis.no more than 2 socket inserts per prosthesis

No more than two replacement liners are provided per prosthesis in twelve months.no more than 2 replacement liners per prosthesis in 12 months

Additional test sockets or socket inserts are supported by documentation of functional or physiologic need, such as residual-limb changes, changed functional needs, irreparable damage, or wear from excessive weight or prosthetic demands.

Required useIndependent daily activities

Expected functional level

Minimum expected levelFunctional level 3

Time frameWithin 3 months of obtaining the device

DocumentationRecords must identify the current and expected functional levels and explain why the current device cannot achieve the expected level

Prosthesis replacement interval

General intervalNo sooner than every 3 years after purchase

Earlier replacementPermitted when applicable coverage criteria support earlier replacement

Repair considerationReplacement is generally not medically necessary when repair would cost less than replacement

Test sockets

Standard limitUp to 2 test sockets per individual prosthesis

Socket typeDiagnostic test sockets

Above-limit requestsAdditional documentation of medical necessity is required for more than 2 test sockets

Socket inserts

Standard limitNo more than 2 socket inserts per individual prosthesis

Use conditionConsidered medically necessary when used with an approved prosthetic device

Above-limit requestsAdditional functional or physiologic need must be documented for additional inserts

Prosthetic liners

Replacement limitNo more than 2 replacement liners per prosthesis in 12 months

Device relationshipThe limit applies separately to each prosthesis

Coverage conditionLiners must be medically necessary and used with an approved prosthetic device

Prosthetic gel stockings

Quantity limit12 in 12 months

SupplyProsthetic gel stockings

Coverage conditionConsidered medically necessary when used with an approved prosthetic device

The prosthetic provider must be duly licensed and/or certified, as applicable, and the services must be provided by or under the direct supervision of a qualified professional prosthetist as permitted by State law.

A certified professional prosthetist must be in good standing with ABC, BOC, or licensed by the State where legally required.

Documentation Required

Demonstrate Need Beyond a Standard Prosthesis

Document that the member's current daily activities exceed the capabilities of a standard lower-limb prosthesis and that the requested device will address those activities.

Record the member's willingness to ambulate and the specific daily activities requiring capabilities beyond a standard device.
Document current and expected functional levels and why the expected level cannot be achieved with the current prosthesis.

Step Therapy

Document the Standard Prosthesis Trial

Before requesting a microprocessor-controlled lower-limb prosthesis, document that the member has used a standard lower-limb prosthesis for independent daily activities for at least three months.

Include medical, physical-therapy/rehabilitation, and prosthetist records supporting the trial.
Document that the member's current activities and functional needs cannot be met with the standard prosthesis.

Documentation Required

Show Why a Body-Powered Prosthesis Is Inadequate

For a myoelectric upper-limb prosthesis, document that a standard body-powered prosthesis is insufficient for activities of daily living or cannot be used by the member.

Describe the upper-limb activities of daily living that remain limited or impossible with the body-powered device.
Document the individual's age (at least two years), residual musculature and microvolt threshold, cognitive ability to operate and train with the device, ability to tolerate its weight, and absence of an underlying neuromuscular disease.

Unsupported block type: documentation

Documentation Required

Document Proof of Delivery

For custom-fit and custom-fabricated items, maintain proof of delivery or direct-delivery documentation; the delivery date is the date of service.

Record the member's name and delivery address.
Record the item description, quantity delivered, delivery date, and member's or designee's signature.

Prior Authorization

Maintain Face-to-Face and Prior-to-Delivery Records

Maintain face-to-face and written-order-prior-to-delivery records supporting authorization, continued need or use, and the medical record requirements for the prosthesis and its components.

Include treating-practitioner medical records and documentation of continued need or use, when applicable.
Ensure the required order and authorization records are completed before delivery.

Documentation Required

Support Clinical and Functional Necessity

Submit clinical and functional documentation establishing medical necessity for the prosthesis, components, additions, and requested functional level.

Include medical-record information, medical necessity for prosthetic components and additions, and gait-analysis results.
Include a PAVET score when appropriate and correct coding that meets all applicable coding guidelines.
Document the member's current and expected functional levels and the functional rationale for each requested component or addition.

Prior Authorization

Support Advanced Lower-Limb Devices

For advanced lower-limb devices, provide a prosthetist evaluation and records supporting the member's functional level, activities, and difficulties with the current prosthesis.

For a microprocessor knee, document extensive prosthetist evaluation and functional level K3 or higher; powered knee coverage is limited to functional level 3 (K3).
For the specified advanced device, document activities and difficulties with the current prosthesis that the new device can address.
For eligible microprocessor knees, document daily long-distance ambulation at variable rates greater than 400 yards, regular uneven-terrain or stair use, adequate cardiopulmonary and neuromuscular reserve, faster-than-baseline ambulation with a standard prosthesis, cognitive ability to master the technology, and functional level 3 or 4.
For a powered knee, document an existing swing-and-stance-phase microprocessor knee and a spine or sound-limb comorbidity impairing hip extension or quadriceps function.

Documentation Required

Justify Additional Sockets or Inserts

Requests exceeding the standard allowance for test sockets or socket inserts require documentation of a functional or physiologic need.

Up to two test/diagnostic sockets and up to two socket inserts may be required per individual prosthesis at the same time.
For additional sockets or inserts, document changes in the residual limb, functional-need changes, irreparable damage, or wear and tear from excessive weight or the prosthetic demands of a very active amputee.

Prior Authorization

Justify Repair or Replacement

For repair or replacement, document the reason clearly and establish that the applicable replacement criteria are met.

Document loss, irreparable damage, or a change in the member's condition that cannot be accommodated by modifying the existing prosthesis.
For device or component damage, document that repair is required, repair would cost more than replacement, the item is not under warranty, and replacement is not due to improper use; provide warranty information.
Repairs may be covered for accidental damage or extensive repairable wear, but payment cannot exceed the estimated replacement cost.

Denial Risk

Criteria or Indication Not Met

Deny or do not submit requests when a condition or diagnosis is listed under the indications of coverage but the applicable medical-necessity criteria are not met; such requests are considered not medically necessary.

Review the health plan's exclusions, benefit requirements, and prior authorization requirements.
If the requested service is for a condition or diagnosis outside the indications of coverage, it is considered experimental, investigational, and unproven rather than merely a criteria failure.

Denial Risk

Match Technology to Functional Need

Do not request higher-technology prostheses when the member's functional needs can be met by a standard non-electronic prosthesis. Microprocessor-controlled lower-limb devices are not medically necessary for functional levels below K3 or when standard technology is sufficient.

A microprocessor-controlled prosthesis for home use or a limited community ambulator, such as for climbing stairs, is not medically necessary when the standard device meets the need.
Specialty sports or fitness components used for activities other than normal daily living are not medically necessary and may be excluded by the member's certificate.

Denial Risk

Justify Costlier Options and Replacement

Do not request a costlier equivalent prosthesis or replacement when a less costly prosthesis meets the member's rehabilitation needs or repair is the less expensive option.

If more than one prosthetic limb meets the member's needs, the costlier prosthetic is not medically necessary.
Replacement is not medically necessary when repair of the limb or its parts costs less than replacement.
Additional features or nonstandard models must be supported as medically necessary and as the lowest-cost effective alternative.

Denial Risk

Avoid Premature Replacement

Replacement is generally limited to no sooner than three years after purchase. A replacement within three years is not medically necessary unless the health plan's applicable conditions and indications of coverage are met.

Document a qualifying change in the member's physiologic condition or functional level, or qualifying loss, irreparable damage, or change in member condition that cannot be accommodated by modification.
For a damaged device, document repair requirements, comparative repair and replacement costs, warranty status, and that damage was not caused by improper use.

Denial Risk

Identify Experimental or Unproven Technology

Do not request devices or technologies classified by the guideline as experimental, investigational, and unproven to affect health outcomes unless benefit or exclusion review requires otherwise.

Examples include microprocessor-controlled ankle-foot devices, myoelectric lower-limb prostheses, implantable myoelectric upper-limb sensors, electric or body-powered partial fingers, and powered lower-limb devices when stated criteria are not met.
Other listed examples include lower-body exoskeleton suits for home use in spinal cord injury, microprocessor legs for gait management in spinal cord injury, Kenevo knees for K-2 walkers, vacuum-assisted socket systems, sensor-and-myoelectric upper-limb components such as the LUKE/DEKA Arm, osseointegrated or osseoanchored prostheses, C-Brace orthoses, 3D-printed anatomic structures, MyoPro orthoses, and robotic rehabilitation for specified degenerative neurologic conditions.
Review the member's certificate for exclusions and the applicable indication and technology classification before submitting authorization.

Limited or unlimited household ambulator

Functional level 2

Functional level2

AbilityHas the ability or potential to ambulate over low-level environmental barriers

ExamplesCurbs, stairs, or uneven surfaces; consistent with a limited community ambulator

Functional level 3

Functional level3

AmbulationHas the ability or potential for variable-cadence ambulation

Environmental accessCan traverse most environmental barriers and may require prosthetic use for vocational, therapeutic, or exercise activity beyond simple locomotion

Functional level 4

Functional level4

AmbulationHas the ability or potential for prosthetic ambulation exceeding basic skills

Demand profileHigh-impact, high-stress, or high-energy demands; consistent with the prosthetic needs of a child, active adult, or athlete

Prosthetic device

DefinitionA prosthetic device is fabricated as a replacement for a missing body part

Controlled technologiesMicroprocessor-controlled, computer-controlled, and myoelectric devices are types of power-enhancement or controlled devices

Device selectionDesign depends on the amputation level, physical condition, ability to ambulate safely, expected functional activity level, and benefit coverage