Aetna · Clinical coverage policy

Aetna Lower Limb Prostheses coverage criteria

Aetna CPB 0578 covers lower limb prostheses and components as medically necessary when prescribed for restoring mobility-related daily activities and matched to the member's Medicare functional (K) level — e.g., basic SACH feet and single-axis knees at K1+, flexible/multi-axial feet and axial rotation ankles at K2+, fluid/pneumatic/microprocessor knees and energy-storing feet at K3+, and high-activity knee frames at K4 — with microprocessor knees reserved for K3+ active community ambulators with non-vascular knee-disarticulation/trans-femoral amputations. Level-0 prostheses, cosmetic/convenience items, sporting/water prostheses, duplicates/upgrades, and a long list of named devices (e.g., osseointegrated systems, robotic exoskeletons, HiFi Socket, Otto Bock Kenevo at the wrong K-level) are not covered or are experimental, and a Standard Written Order plus supporting medical-record documentation (including a physical therapist evaluation for K3+) is required.

Policy CPB 0578 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0578

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0578 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Lower Limb Prostheses (CPT L5000), and what gets it denied?

Path
Aetna CPB 0578 covers lower limb prostheses and components as medically necessary when prescribed for restoring mobility-related daily activities and matched to the member's Medicare functional (K) level — e.g., basic SACH feet and single-axis knees at K1+, flexible/multi-axial feet and axial rotation ankles at K2+, fluid/pneumatic/microprocessor knees and energy-storing feet at K3+, and high-activity knee frames at K4 — with microprocessor knees reserved for K3+ active community ambulators with non-vascular knee-disarticulation/trans-femoral amputations. Level-0 prostheses, cosmetic/convenience items, sporting/water prostheses, duplicates/upgrades, and a long list of named devices (e.g., osseointegrated systems, robotic exoskeletons, HiFi Socket, Otto Bock Kenevo at the wrong K-level) are not covered or are experimental, and a Standard Written Order plus supporting medical-record documentation (including a physical therapist evaluation for K3+) is required. Coverage criteria include: General gate — Aetna considers an orthosis/prosthesis medically necessary only when ALL of the following are met: (1) prescribed by a physician, nurse practitioner, podiatrist or other qualified health professional per State law; (2) it will significantly improve or restore physical functions required for mobility-related activities of daily living (MRADLs); (3) the member's physician or licensed practitioner has determined, based on physical examination, that it allows the member to perform ADLs; (4) it is provided within six months of the prescription date; (5) services are performed by a duly licensed/certified orthotic and/or prosthetic provider within applicable scope of practice; (6) the service complexity requires a licensed/certified professional, or is provided under direct supervision of a licensed ancillary person per state law; AND (7) the orthotist/prosthetist is certified and in good standing with ONE OR MORE of: American Board for Certification (ABC), Board of Certification/Accreditation (BOC), or state license where legally required.; Lower limb prostheses for performing normal daily activities — medically necessary when ALL of: (1) member is motivated to ambulate; (2) member meets the specific lower-limb prosthesis criteria set forth in the policy; AND (3) member will reach or maintain a defined functional state within a reasonable period of time.; Functional Classification Level 0 (K0): no ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility — a lower limb prosthesis is NOT medically necessary at this level.; Functional Classification Level 1 (K1): has the ability or potential to use a prosthesis for transfers or for ambulation on level surfaces at a fixed cadence; typical of the limited and unlimited household ambulator.; Functional Classification Level 2 (K2): has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces; typical of the limited community ambulator.; Functional Classification Level 3 (K3): has the ability or potential for ambulation with variable cadence; typical of the community ambulator able to traverse most environmental barriers and who may have vocational, therapeutic, or exercise activity demanding prosthetic use beyond simple locomotion.; Functional Classification Level 4 (K4): has the ability or potential for prosthetic ambulation exceeding basic ambulation skills, exhibiting high impact, stress, or energy levels; typical of the prosthetic demands of a child, active adult, or athlete.; Functional-level documentation requirement: the expectation of functional ability must be clearly documented in the prosthetist's records — a simple K-modifier entry is insufficient; for K3 or above a documented evaluation from a physical therapist is required to establish functional levels and activities, and the member's history/current condition must support the functional level designation by both prosthetist and physical therapist.; Foot — Solid ankle-cushion heel (SACH) foot is medically necessary for functional level 1 or above.; Foot — External keel SACH foot OR single axis ankle/foot is medically necessary for functional level 1 or above.; Foot — Flexible-keel foot OR multi-axial ankle/foot is medically necessary for functional level 2 or above.; Foot — Flex foot system, energy-storing foot, multi-axial ankle/foot, dynamic response foot with multi-axial ankle, shank foot system with vertical-loaded pylon, flex-walk system, or equal is medically necessary for functional level 3 or above.; Foot — replacement of a foot cover (foot shell) is limited to a maximum of one foot cover replacement per prosthetic foot annually as medically necessary (a damaged foot cover replacement is billed using the repair code).; Knee — Single axis constant friction knee and other basic knee systems are medically necessary for functional level 1 or above.; Knee — Fluid or pneumatic knee is medically necessary for functional level 3 or above.; Knee — High-activity knee control frame is medically necessary for functional level 4.; Knee — Fluid, pneumatic, or electronic/microprocessor knee is medically necessary for knee disarticulation, trans-femoral, or hip disarticulation amputation at functional level 3 or above.; Ankle — Axial rotation unit is medically necessary for functional level 2 or above (only one axial rotation per ankle device/prosthesis is medically necessary).; Hip — Pneumatic or hydraulic polycentric hip joint is medically necessary for functional level 3 or above.; Sockets — Up to two test (diagnostic) sockets per individual prosthesis are medically necessary; more than 2 test sockets require additional documentation of medical necessity.; Sockets — No more than 2 socket inserts per individual prosthesis at the same time are medically necessary.; Sockets — Socket replacement is medically necessary with adequate documentation of functional/physiological need, including ONE of: changes in the residual limb; changes in functional need; OR irreparable damage or wear/tear due to excessive weight or the prosthetic demands of very active amputees.; Sockets — When a prosthetic foot, knee, or other component is still under warranty, socket replacement should be the first-line treatment; an alignable system is included in socket replacement and not separately payable unless a medical need for replacement is documented.; Accessory — Stump stockings and harnesses (including replacements) are medically necessary when essential to effective use of the artificial limb.; Accessory — No more than 1 harness/suspension system per limb is medically necessary.; Accessory — Prosthetic sheaths/socks, including a gel cushion layer (prosthetic gel stockings), are medically necessary up to 12 in 12 months.; Accessory — No more than 2 socket inserts per individual prosthesis are medically necessary.; Accessory — No more than 2 replacement liners per prosthesis in 12 months are medically necessary.; Accessory — Static compression garments (shrinkers, stump stockings for edema) are medically necessary for members with ONE of: (a) amputation of an upper limb between the wrist and shoulder; OR (b) amputation of a lower limb between the ankle and hip.; Accessory — No more than 2 static compression garments per limb every 6 months are medically necessary.; Accessory — No more than 2 suspension sleeves per limb every 6 months are medically necessary.; Accessory — Custom socket inserts (liners) are medically necessary with clinical documentation by the treating practitioner of an atypical amputation and of medical necessity.; Microprocessor-controlled leg prostheses (swing and stance phase) are medically necessary in otherwise healthy, active community-ambulating members at functional K-level 3 or above with knee disarticulation or trans-femoral amputation from a non-vascular cause (usually trauma or tumor), for whom the prosthesis can be fitted and programmed by a qualified prosthetist trained to do so.; Powered flexion-extension assist is medically necessary only when the member meets ALL of: (1) has a microprocessor (swing-and-stance-phase type) controlled (electronic) knee; AND (2) is K3 functional level ONLY; AND (3) weighs greater than 110 lbs and less than 275 lbs; AND (4) has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3-level function with a microprocessor-controlled knee alone; AND (5) is able to make use of a product requiring daily charging; AND (6) is able to understand and respond to error alerts and alarms indicating device function problems.; Microprocessor-controlled ankle — Microprocessor-controlled ankle-foot prostheses (e.g., PowerFoot BiOM, Proprio Foot) are medically necessary for functional level 3 or above.; Prosthetic shoe for partial foot amputation is medically necessary when it is an integral part of a covered basic lower limb prosthetic device.; Protective outer surface covering systems are medically necessary for members with special needs for protection against unusually harsh environmental situations where necessary to protect the lower limb prosthesis beyond the protection level of standard covers (NOT for cosmetic/convenience reasons or everyday usage in a typical environment); the protective cover type (manufacturer name, make, model, type) must be documented in the practitioner's notes for correct coding.. Applies to 189 codes: L5000, L5010, L5020, L5050, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5400, L5420, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L7510, L7520, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8485.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification/prior-authorization process. It instead requires a Standard Written Order (SWO) to be communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO, the claim is denied as not medically necessary. The SWO must include the member's name or ID number, order date, a general description of the item (HCPCS code, narrative, or brand name/model number), all concurrently ordered separately billed options/accessories/supplies listed separately, each item's individual HCPCS code and quantity, and the treating practitioner's name, NPI, and signature. Suppliers must also maintain Proof of Delivery (POD) available to Aetna on request. Documentation: Standard Written Order (SWO) communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO the claim is denied as not medically necessary. The SWO must include: member's name or identification number; order date; general description of the item (HCPCS code, narrative, or brand name/model number); for a base item, all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies separately billed (listed separately); each item/service's individual HCPCS code and quantity; the treating practitioner's name and National Provider Identifier (NPI); and the treating practitioner's signature.; Proof of Delivery (POD): suppliers must maintain POD documentation and make it available to Aetna upon request; services without appropriate POD are denied as not medically necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; Sufficient medical information must be in the medical record demonstrating that all applicable coverage criteria are met.; For K3 or above, a documented evaluation from a physical therapist is required to establish functional levels and activities; the expectation of functional ability must be clearly documented in the prosthetist's records (a simple K-modifier entry is insufficient).; Functional/physiological documentation supporting socket replacement (changes in the residual limb, changes in functional need, or irreparable damage/wear).; Clinical documentation by the treating practitioner of an atypical amputation and medical necessity for custom socket inserts (liners).; For protective outer surface covering systems, documentation of the protective cover type (manufacturer name, make, model, type) in the practitioner's notes.; Supplier-prepared statements, physician attestations, and the practitioner's order do not by themselves provide sufficient documentation of medical necessity even if signed; the medical record must contain corroborating information, and records from suppliers/healthcare professionals with a financial interest in the claim outcome are not sufficient by themselves.; Treating practitioner is defined as a physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered the treating practitioner for ordering purposes.
Trap
Policy exclusions and limitations: A user-adjustable heel height feature on a prosthetic foot is NOT medically necessary.; Repair or replacement of a foot cover for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Test (diagnostic) sockets for immediate post-surgical or early-fitted (immediate) prostheses are NOT medically necessary.; Socket replacement codes are duplicative and NOT medically necessary when entire prosthesis components (e.g., feet, knees) are billed with a socket replacement code (i.e., socket replacement codes must not be used when replacing an entire prosthesis).; Items billed for replacement that are still under manufacturer warranty are NOT medically necessary.; Prosthetic donning sleeve is NOT medically necessary.; Passive/restorative devices (silicone devices) to make the limb lifelike are considered cosmetic (not covered).; Custom-shaped prosthetic covers are considered cosmetic unless medical function is documented with documentation of medical need (custom-made prosthetic covers are typically foam, cosmetically shaped).; Silver-impregnated garments (shrinkers, socks, sheaths) are NOT medically necessary due to insufficient evidence of superiority over standard garments.; Donning tubes or devices for applying a compression garment are NOT medically necessary.; Push-button rotation device allowing the user to rotate the prosthesis between the socket and the knee/shin/foot region is considered a convenience item (not covered).; Gaitor sealing sleeves are considered a convenience/cosmetic item (not covered).; 3-D printed, CAD-CAM, or similar prosthetic covers are considered cosmetic (not covered).; Duplication or upgrade of a functional prosthesis is NOT medically necessary.; A lower limb prosthesis for functional level 0 is NOT medically necessary.; Otto Bock Kenevo microprocessor-controlled knee for functional level 3 or above is NOT medically necessary.; Prosthetic devices/components primarily for cosmesis are NOT medically necessary.; Prosthetics used for activities other than normal daily living, including leisure/sporting activities (e.g., skiing, swimming), are NOT medically necessary.; Repair or replacement of a prosthesis for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Repair or replacement of parts of a duplicate prosthesis is NOT medically necessary.; Test sockets for an immediate prosthesis are NOT medically necessary.; Water prosthesis (designed for showering or swimming) is NOT medically necessary.; Adjustable click prostheses (e.g., Revo, RevoFit, Boa click systems) are experimental, investigational, or unproven.; Protective cover for microprocessor knees (e.g., C-leg Protector or similar), Bionic Protector for Rheo, UNYQ Prosthetic Covers, Limb-Art Covers (or similar), and 3-D printed covers are experimental, investigational, or unproven.; DAW Sure Stance Knee is experimental, investigational, or unproven.; Endo-skeletal above-knee positioning device allowing 360-degree rotation and locking the endo-skeletal prosthetic knee/foot in neutral position (predicate: Ottobock 4R57 Rotation Adapter) is experimental, investigational, or unproven.; HiFi Interface System (HiFi Socket) is experimental, investigational, or unproven.; Lower limb prostheses for all other indications (not listed as medically necessary) are experimental, investigational, or unproven.; Microprocessor-controlled leg prostheses for gait management in spinal cord injury are experimental, investigational, or unproven.; Osseointegrated lower limb prosthetic devices (with or without microprocessor control) are experimental, investigational, or unproven.; Ossur Pivot Foot is experimental, investigational, or unproven.; Ossur Symbiotic Leg is experimental, investigational, or unproven.; Otto Bock Kenevo microprocessor-controlled knee for members with functional level 2 or below is experimental, investigational, or unproven.; Powered ankle (addition, endoskeletal ankle-foot or ankle system, power assist, includes motor) is experimental, investigational, or unproven.; Robotic lower body exoskeleton suits (e.g., ReWalk, Argo Medical Technologies) are experimental, investigational, or unproven.; Otto Bock Genium knee system is NOT a covered item because it is not PDAC verified (billing it would be incorrect coding/unbundling).; Warranties/guarantees beyond the base warranty included in the device are NOT a medical benefit; additional warranties/guarantees beyond the included base or manufacturer warranty are considered non-medically-necessary convenience items.; Evaluation of the member, measurement, casting, and fitting/adjustments of the prosthesis are included in the prosthesis allowance and are not separately payable.; CAD-CAM technology for prosthesis fabrication is included in the allowance and is not separately payable.; For powered base items (containing a power source/battery), all necessary batteries and battery chargers are included at the time the base item is billed; batteries or chargers billed concurrently are not separately payable.; Foot covers (foot shells) are included in the prosthetic foot reimbursement and are not separately payable.; Except for items with specific HCPCS codes, there is no separate billing/payment for a component or feature of a microprocessor-controlled knee, including real-time gait analysis, continuous gait assessment, and electronically controlled static stance regulator. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0578 — Lower Limb Prostheses

Coverage criteria

  • General gate — Aetna considers an orthosis/prosthesis medically necessary only when ALL of the following are met: (1) prescribed by a physician, nurse practitioner, podiatrist or other qualified health professional per State law; (2) it will significantly improve or restore physical functions required for mobility-related activities of daily living (MRADLs); (3) the member's physician or licensed practitioner has determined, based on physical examination, that it allows the member to perform ADLs; (4) it is provided within six months of the prescription date; (5) services are performed by a duly licensed/certified orthotic and/or prosthetic provider within applicable scope of practice; (6) the service complexity requires a licensed/certified professional, or is provided under direct supervision of a licensed ancillary person per state law; AND (7) the orthotist/prosthetist is certified and in good standing with ONE OR MORE of: American Board for Certification (ABC), Board of Certification/Accreditation (BOC), or state license where legally required.
  • Lower limb prostheses for performing normal daily activities — medically necessary when ALL of: (1) member is motivated to ambulate; (2) member meets the specific lower-limb prosthesis criteria set forth in the policy; AND (3) member will reach or maintain a defined functional state within a reasonable period of time.
  • Functional Classification Level 0 (K0): no ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility — a lower limb prosthesis is NOT medically necessary at this level.
  • Functional Classification Level 1 (K1): has the ability or potential to use a prosthesis for transfers or for ambulation on level surfaces at a fixed cadence; typical of the limited and unlimited household ambulator.
  • Functional Classification Level 2 (K2): has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces; typical of the limited community ambulator.
  • Functional Classification Level 3 (K3): has the ability or potential for ambulation with variable cadence; typical of the community ambulator able to traverse most environmental barriers and who may have vocational, therapeutic, or exercise activity demanding prosthetic use beyond simple locomotion.
  • Functional Classification Level 4 (K4): has the ability or potential for prosthetic ambulation exceeding basic ambulation skills, exhibiting high impact, stress, or energy levels; typical of the prosthetic demands of a child, active adult, or athlete.
  • Functional-level documentation requirement: the expectation of functional ability must be clearly documented in the prosthetist's records — a simple K-modifier entry is insufficient; for K3 or above a documented evaluation from a physical therapist is required to establish functional levels and activities, and the member's history/current condition must support the functional level designation by both prosthetist and physical therapist.
  • Foot — Solid ankle-cushion heel (SACH) foot is medically necessary for functional level 1 or above.
  • Foot — External keel SACH foot OR single axis ankle/foot is medically necessary for functional level 1 or above.
  • Foot — Flexible-keel foot OR multi-axial ankle/foot is medically necessary for functional level 2 or above.
  • Foot — Flex foot system, energy-storing foot, multi-axial ankle/foot, dynamic response foot with multi-axial ankle, shank foot system with vertical-loaded pylon, flex-walk system, or equal is medically necessary for functional level 3 or above.
  • Foot — replacement of a foot cover (foot shell) is limited to a maximum of one foot cover replacement per prosthetic foot annually as medically necessary (a damaged foot cover replacement is billed using the repair code).
  • Knee — Single axis constant friction knee and other basic knee systems are medically necessary for functional level 1 or above.
  • Knee — Fluid or pneumatic knee is medically necessary for functional level 3 or above.
  • Knee — High-activity knee control frame is medically necessary for functional level 4.
  • Knee — Fluid, pneumatic, or electronic/microprocessor knee is medically necessary for knee disarticulation, trans-femoral, or hip disarticulation amputation at functional level 3 or above.
  • Ankle — Axial rotation unit is medically necessary for functional level 2 or above (only one axial rotation per ankle device/prosthesis is medically necessary).
  • Hip — Pneumatic or hydraulic polycentric hip joint is medically necessary for functional level 3 or above.
  • Sockets — Up to two test (diagnostic) sockets per individual prosthesis are medically necessary; more than 2 test sockets require additional documentation of medical necessity.
  • Sockets — No more than 2 socket inserts per individual prosthesis at the same time are medically necessary.
  • Sockets — Socket replacement is medically necessary with adequate documentation of functional/physiological need, including ONE of: changes in the residual limb; changes in functional need; OR irreparable damage or wear/tear due to excessive weight or the prosthetic demands of very active amputees.
  • Sockets — When a prosthetic foot, knee, or other component is still under warranty, socket replacement should be the first-line treatment; an alignable system is included in socket replacement and not separately payable unless a medical need for replacement is documented.
  • Accessory — Stump stockings and harnesses (including replacements) are medically necessary when essential to effective use of the artificial limb.
  • Accessory — No more than 1 harness/suspension system per limb is medically necessary.
  • Accessory — Prosthetic sheaths/socks, including a gel cushion layer (prosthetic gel stockings), are medically necessary up to 12 in 12 months.
  • Accessory — No more than 2 socket inserts per individual prosthesis are medically necessary.
  • Accessory — No more than 2 replacement liners per prosthesis in 12 months are medically necessary.
  • Accessory — Static compression garments (shrinkers, stump stockings for edema) are medically necessary for members with ONE of: (a) amputation of an upper limb between the wrist and shoulder; OR (b) amputation of a lower limb between the ankle and hip.
  • Accessory — No more than 2 static compression garments per limb every 6 months are medically necessary.
  • Accessory — No more than 2 suspension sleeves per limb every 6 months are medically necessary.
  • Accessory — Custom socket inserts (liners) are medically necessary with clinical documentation by the treating practitioner of an atypical amputation and of medical necessity.
  • Microprocessor-controlled leg prostheses (swing and stance phase) are medically necessary in otherwise healthy, active community-ambulating members at functional K-level 3 or above with knee disarticulation or trans-femoral amputation from a non-vascular cause (usually trauma or tumor), for whom the prosthesis can be fitted and programmed by a qualified prosthetist trained to do so.
  • Powered flexion-extension assist is medically necessary only when the member meets ALL of: (1) has a microprocessor (swing-and-stance-phase type) controlled (electronic) knee; AND (2) is K3 functional level ONLY; AND (3) weighs greater than 110 lbs and less than 275 lbs; AND (4) has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3-level function with a microprocessor-controlled knee alone; AND (5) is able to make use of a product requiring daily charging; AND (6) is able to understand and respond to error alerts and alarms indicating device function problems.
  • Microprocessor-controlled ankle — Microprocessor-controlled ankle-foot prostheses (e.g., PowerFoot BiOM, Proprio Foot) are medically necessary for functional level 3 or above.
  • Prosthetic shoe for partial foot amputation is medically necessary when it is an integral part of a covered basic lower limb prosthetic device.
  • Protective outer surface covering systems are medically necessary for members with special needs for protection against unusually harsh environmental situations where necessary to protect the lower limb prosthesis beyond the protection level of standard covers (NOT for cosmetic/convenience reasons or everyday usage in a typical environment); the protective cover type (manufacturer name, make, model, type) must be documented in the practitioner's notes for correct coding.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Standard Written Order (SWO) communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO the claim is denied as not medically necessary. The SWO must include: member's name or identification number; order date; general description of the item (HCPCS code, narrative, or brand name/model number); for a base item, all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies separately billed (listed separately); each item/service's individual HCPCS code and quantity; the treating practitioner's name and National Provider Identifier (NPI); and the treating practitioner's signature.
  • Proof of Delivery (POD): suppliers must maintain POD documentation and make it available to Aetna upon request; services without appropriate POD are denied as not medically necessary.
  • A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.
  • Sufficient medical information must be in the medical record demonstrating that all applicable coverage criteria are met.
  • For K3 or above, a documented evaluation from a physical therapist is required to establish functional levels and activities; the expectation of functional ability must be clearly documented in the prosthetist's records (a simple K-modifier entry is insufficient).
  • Functional/physiological documentation supporting socket replacement (changes in the residual limb, changes in functional need, or irreparable damage/wear).
  • Clinical documentation by the treating practitioner of an atypical amputation and medical necessity for custom socket inserts (liners).
  • For protective outer surface covering systems, documentation of the protective cover type (manufacturer name, make, model, type) in the practitioner's notes.
  • Supplier-prepared statements, physician attestations, and the practitioner's order do not by themselves provide sufficient documentation of medical necessity even if signed; the medical record must contain corroborating information, and records from suppliers/healthcare professionals with a financial interest in the claim outcome are not sufficient by themselves.
  • Treating practitioner is defined as a physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered the treating practitioner for ordering purposes.

Frequently asked questions

When does Aetna cover Lower Limb Prostheses (CPT L5000), and what gets it denied?
Aetna CPB 0578 covers lower limb prostheses and components as medically necessary when prescribed for restoring mobility-related daily activities and matched to the member's Medicare functional (K) level — e.g., basic SACH feet and single-axis knees at K1+, flexible/multi-axial feet and axial rotation ankles at K2+, fluid/pneumatic/microprocessor knees and energy-storing feet at K3+, and high-activity knee frames at K4 — with microprocessor knees reserved for K3+ active community ambulators with non-vascular knee-disarticulation/trans-femoral amputations. Level-0 prostheses, cosmetic/convenience items, sporting/water prostheses, duplicates/upgrades, and a long list of named devices (e.g., osseointegrated systems, robotic exoskeletons, HiFi Socket, Otto Bock Kenevo at the wrong K-level) are not covered or are experimental, and a Standard Written Order plus supporting medical-record documentation (including a physical therapist evaluation for K3+) is required. Coverage criteria include: General gate — Aetna considers an orthosis/prosthesis medically necessary only when ALL of the following are met: (1) prescribed by a physician, nurse practitioner, podiatrist or other qualified health professional per State law; (2) it will significantly improve or restore physical functions required for mobility-related activities of daily living (MRADLs); (3) the member's physician or licensed practitioner has determined, based on physical examination, that it allows the member to perform ADLs; (4) it is provided within six months of the prescription date; (5) services are performed by a duly licensed/certified orthotic and/or prosthetic provider within applicable scope of practice; (6) the service complexity requires a licensed/certified professional, or is provided under direct supervision of a licensed ancillary person per state law; AND (7) the orthotist/prosthetist is certified and in good standing with ONE OR MORE of: American Board for Certification (ABC), Board of Certification/Accreditation (BOC), or state license where legally required.; Lower limb prostheses for performing normal daily activities — medically necessary when ALL of: (1) member is motivated to ambulate; (2) member meets the specific lower-limb prosthesis criteria set forth in the policy; AND (3) member will reach or maintain a defined functional state within a reasonable period of time.; Functional Classification Level 0 (K0): no ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility — a lower limb prosthesis is NOT medically necessary at this level.; Functional Classification Level 1 (K1): has the ability or potential to use a prosthesis for transfers or for ambulation on level surfaces at a fixed cadence; typical of the limited and unlimited household ambulator.; Functional Classification Level 2 (K2): has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces; typical of the limited community ambulator.; Functional Classification Level 3 (K3): has the ability or potential for ambulation with variable cadence; typical of the community ambulator able to traverse most environmental barriers and who may have vocational, therapeutic, or exercise activity demanding prosthetic use beyond simple locomotion.; Functional Classification Level 4 (K4): has the ability or potential for prosthetic ambulation exceeding basic ambulation skills, exhibiting high impact, stress, or energy levels; typical of the prosthetic demands of a child, active adult, or athlete.; Functional-level documentation requirement: the expectation of functional ability must be clearly documented in the prosthetist's records — a simple K-modifier entry is insufficient; for K3 or above a documented evaluation from a physical therapist is required to establish functional levels and activities, and the member's history/current condition must support the functional level designation by both prosthetist and physical therapist.; Foot — Solid ankle-cushion heel (SACH) foot is medically necessary for functional level 1 or above.; Foot — External keel SACH foot OR single axis ankle/foot is medically necessary for functional level 1 or above.; Foot — Flexible-keel foot OR multi-axial ankle/foot is medically necessary for functional level 2 or above.; Foot — Flex foot system, energy-storing foot, multi-axial ankle/foot, dynamic response foot with multi-axial ankle, shank foot system with vertical-loaded pylon, flex-walk system, or equal is medically necessary for functional level 3 or above.; Foot — replacement of a foot cover (foot shell) is limited to a maximum of one foot cover replacement per prosthetic foot annually as medically necessary (a damaged foot cover replacement is billed using the repair code).; Knee — Single axis constant friction knee and other basic knee systems are medically necessary for functional level 1 or above.; Knee — Fluid or pneumatic knee is medically necessary for functional level 3 or above.; Knee — High-activity knee control frame is medically necessary for functional level 4.; Knee — Fluid, pneumatic, or electronic/microprocessor knee is medically necessary for knee disarticulation, trans-femoral, or hip disarticulation amputation at functional level 3 or above.; Ankle — Axial rotation unit is medically necessary for functional level 2 or above (only one axial rotation per ankle device/prosthesis is medically necessary).; Hip — Pneumatic or hydraulic polycentric hip joint is medically necessary for functional level 3 or above.; Sockets — Up to two test (diagnostic) sockets per individual prosthesis are medically necessary; more than 2 test sockets require additional documentation of medical necessity.; Sockets — No more than 2 socket inserts per individual prosthesis at the same time are medically necessary.; Sockets — Socket replacement is medically necessary with adequate documentation of functional/physiological need, including ONE of: changes in the residual limb; changes in functional need; OR irreparable damage or wear/tear due to excessive weight or the prosthetic demands of very active amputees.; Sockets — When a prosthetic foot, knee, or other component is still under warranty, socket replacement should be the first-line treatment; an alignable system is included in socket replacement and not separately payable unless a medical need for replacement is documented.; Accessory — Stump stockings and harnesses (including replacements) are medically necessary when essential to effective use of the artificial limb.; Accessory — No more than 1 harness/suspension system per limb is medically necessary.; Accessory — Prosthetic sheaths/socks, including a gel cushion layer (prosthetic gel stockings), are medically necessary up to 12 in 12 months.; Accessory — No more than 2 socket inserts per individual prosthesis are medically necessary.; Accessory — No more than 2 replacement liners per prosthesis in 12 months are medically necessary.; Accessory — Static compression garments (shrinkers, stump stockings for edema) are medically necessary for members with ONE of: (a) amputation of an upper limb between the wrist and shoulder; OR (b) amputation of a lower limb between the ankle and hip.; Accessory — No more than 2 static compression garments per limb every 6 months are medically necessary.; Accessory — No more than 2 suspension sleeves per limb every 6 months are medically necessary.; Accessory — Custom socket inserts (liners) are medically necessary with clinical documentation by the treating practitioner of an atypical amputation and of medical necessity.; Microprocessor-controlled leg prostheses (swing and stance phase) are medically necessary in otherwise healthy, active community-ambulating members at functional K-level 3 or above with knee disarticulation or trans-femoral amputation from a non-vascular cause (usually trauma or tumor), for whom the prosthesis can be fitted and programmed by a qualified prosthetist trained to do so.; Powered flexion-extension assist is medically necessary only when the member meets ALL of: (1) has a microprocessor (swing-and-stance-phase type) controlled (electronic) knee; AND (2) is K3 functional level ONLY; AND (3) weighs greater than 110 lbs and less than 275 lbs; AND (4) has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3-level function with a microprocessor-controlled knee alone; AND (5) is able to make use of a product requiring daily charging; AND (6) is able to understand and respond to error alerts and alarms indicating device function problems.; Microprocessor-controlled ankle — Microprocessor-controlled ankle-foot prostheses (e.g., PowerFoot BiOM, Proprio Foot) are medically necessary for functional level 3 or above.; Prosthetic shoe for partial foot amputation is medically necessary when it is an integral part of a covered basic lower limb prosthetic device.; Protective outer surface covering systems are medically necessary for members with special needs for protection against unusually harsh environmental situations where necessary to protect the lower limb prosthesis beyond the protection level of standard covers (NOT for cosmetic/convenience reasons or everyday usage in a typical environment); the protective cover type (manufacturer name, make, model, type) must be documented in the practitioner's notes for correct coding.. Applies to 189 codes: L5000, L5010, L5020, L5050, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5400, L5420, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L7510, L7520, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8485. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification/prior-authorization process. It instead requires a Standard Written Order (SWO) to be communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO, the claim is denied as not medically necessary. The SWO must include the member's name or ID number, order date, a general description of the item (HCPCS code, narrative, or brand name/model number), all concurrently ordered separately billed options/accessories/supplies listed separately, each item's individual HCPCS code and quantity, and the treating practitioner's name, NPI, and signature. Suppliers must also maintain Proof of Delivery (POD) available to Aetna on request. Documentation: Standard Written Order (SWO) communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO the claim is denied as not medically necessary. The SWO must include: member's name or identification number; order date; general description of the item (HCPCS code, narrative, or brand name/model number); for a base item, all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies separately billed (listed separately); each item/service's individual HCPCS code and quantity; the treating practitioner's name and National Provider Identifier (NPI); and the treating practitioner's signature.; Proof of Delivery (POD): suppliers must maintain POD documentation and make it available to Aetna upon request; services without appropriate POD are denied as not medically necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; Sufficient medical information must be in the medical record demonstrating that all applicable coverage criteria are met.; For K3 or above, a documented evaluation from a physical therapist is required to establish functional levels and activities; the expectation of functional ability must be clearly documented in the prosthetist's records (a simple K-modifier entry is insufficient).; Functional/physiological documentation supporting socket replacement (changes in the residual limb, changes in functional need, or irreparable damage/wear).; Clinical documentation by the treating practitioner of an atypical amputation and medical necessity for custom socket inserts (liners).; For protective outer surface covering systems, documentation of the protective cover type (manufacturer name, make, model, type) in the practitioner's notes.; Supplier-prepared statements, physician attestations, and the practitioner's order do not by themselves provide sufficient documentation of medical necessity even if signed; the medical record must contain corroborating information, and records from suppliers/healthcare professionals with a financial interest in the claim outcome are not sufficient by themselves.; Treating practitioner is defined as a physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered the treating practitioner for ordering purposes. Policy exclusions and limitations: A user-adjustable heel height feature on a prosthetic foot is NOT medically necessary.; Repair or replacement of a foot cover for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Test (diagnostic) sockets for immediate post-surgical or early-fitted (immediate) prostheses are NOT medically necessary.; Socket replacement codes are duplicative and NOT medically necessary when entire prosthesis components (e.g., feet, knees) are billed with a socket replacement code (i.e., socket replacement codes must not be used when replacing an entire prosthesis).; Items billed for replacement that are still under manufacturer warranty are NOT medically necessary.; Prosthetic donning sleeve is NOT medically necessary.; Passive/restorative devices (silicone devices) to make the limb lifelike are considered cosmetic (not covered).; Custom-shaped prosthetic covers are considered cosmetic unless medical function is documented with documentation of medical need (custom-made prosthetic covers are typically foam, cosmetically shaped).; Silver-impregnated garments (shrinkers, socks, sheaths) are NOT medically necessary due to insufficient evidence of superiority over standard garments.; Donning tubes or devices for applying a compression garment are NOT medically necessary.; Push-button rotation device allowing the user to rotate the prosthesis between the socket and the knee/shin/foot region is considered a convenience item (not covered).; Gaitor sealing sleeves are considered a convenience/cosmetic item (not covered).; 3-D printed, CAD-CAM, or similar prosthetic covers are considered cosmetic (not covered).; Duplication or upgrade of a functional prosthesis is NOT medically necessary.; A lower limb prosthesis for functional level 0 is NOT medically necessary.; Otto Bock Kenevo microprocessor-controlled knee for functional level 3 or above is NOT medically necessary.; Prosthetic devices/components primarily for cosmesis are NOT medically necessary.; Prosthetics used for activities other than normal daily living, including leisure/sporting activities (e.g., skiing, swimming), are NOT medically necessary.; Repair or replacement of a prosthesis for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Repair or replacement of parts of a duplicate prosthesis is NOT medically necessary.; Test sockets for an immediate prosthesis are NOT medically necessary.; Water prosthesis (designed for showering or swimming) is NOT medically necessary.; Adjustable click prostheses (e.g., Revo, RevoFit, Boa click systems) are experimental, investigational, or unproven.; Protective cover for microprocessor knees (e.g., C-leg Protector or similar), Bionic Protector for Rheo, UNYQ Prosthetic Covers, Limb-Art Covers (or similar), and 3-D printed covers are experimental, investigational, or unproven.; DAW Sure Stance Knee is experimental, investigational, or unproven.; Endo-skeletal above-knee positioning device allowing 360-degree rotation and locking the endo-skeletal prosthetic knee/foot in neutral position (predicate: Ottobock 4R57 Rotation Adapter) is experimental, investigational, or unproven.; HiFi Interface System (HiFi Socket) is experimental, investigational, or unproven.; Lower limb prostheses for all other indications (not listed as medically necessary) are experimental, investigational, or unproven.; Microprocessor-controlled leg prostheses for gait management in spinal cord injury are experimental, investigational, or unproven.; Osseointegrated lower limb prosthetic devices (with or without microprocessor control) are experimental, investigational, or unproven.; Ossur Pivot Foot is experimental, investigational, or unproven.; Ossur Symbiotic Leg is experimental, investigational, or unproven.; Otto Bock Kenevo microprocessor-controlled knee for members with functional level 2 or below is experimental, investigational, or unproven.; Powered ankle (addition, endoskeletal ankle-foot or ankle system, power assist, includes motor) is experimental, investigational, or unproven.; Robotic lower body exoskeleton suits (e.g., ReWalk, Argo Medical Technologies) are experimental, investigational, or unproven.; Otto Bock Genium knee system is NOT a covered item because it is not PDAC verified (billing it would be incorrect coding/unbundling).; Warranties/guarantees beyond the base warranty included in the device are NOT a medical benefit; additional warranties/guarantees beyond the included base or manufacturer warranty are considered non-medically-necessary convenience items.; Evaluation of the member, measurement, casting, and fitting/adjustments of the prosthesis are included in the prosthesis allowance and are not separately payable.; CAD-CAM technology for prosthesis fabrication is included in the allowance and is not separately payable.; For powered base items (containing a power source/battery), all necessary batteries and battery chargers are included at the time the base item is billed; batteries or chargers billed concurrently are not separately payable.; Foot covers (foot shells) are included in the prosthetic foot reimbursement and are not separately payable.; Except for items with specific HCPCS codes, there is no separate billing/payment for a component or feature of a microprocessor-controlled knee, including real-time gait analysis, continuous gait assessment, and electronically controlled static stance regulator. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Lower Limb Prostheses?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification/prior-authorization process. It instead requires a Standard Written Order (SWO) to be communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO, the claim is denied as not medically necessary. The SWO must include the member's name or ID number, order date, a general description of the item (HCPCS code, narrative, or brand name/model number), all concurrently ordered separately billed options/accessories/supplies listed separately, each item's individual HCPCS code and quantity, and the treating practitioner's name, NPI, and signature. Suppliers must also maintain Proof of Delivery (POD) available to Aetna on request. Documentation: Standard Written Order (SWO) communicated to the supplier before the claim is submitted; if a supplier bills without a received completed SWO the claim is denied as not medically necessary. The SWO must include: member's name or identification number; order date; general description of the item (HCPCS code, narrative, or brand name/model number); for a base item, all concurrently ordered options/accessories/additional features that are separately billed or require an upgraded code (listed separately); for supplies, all concurrently ordered supplies separately billed (listed separately); each item/service's individual HCPCS code and quantity; the treating practitioner's name and National Provider Identifier (NPI); and the treating practitioner's signature.; Proof of Delivery (POD): suppliers must maintain POD documentation and make it available to Aetna upon request; services without appropriate POD are denied as not medically necessary.; A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.; Sufficient medical information must be in the medical record demonstrating that all applicable coverage criteria are met.; For K3 or above, a documented evaluation from a physical therapist is required to establish functional levels and activities; the expectation of functional ability must be clearly documented in the prosthetist's records (a simple K-modifier entry is insufficient).; Functional/physiological documentation supporting socket replacement (changes in the residual limb, changes in functional need, or irreparable damage/wear).; Clinical documentation by the treating practitioner of an atypical amputation and medical necessity for custom socket inserts (liners).; For protective outer surface covering systems, documentation of the protective cover type (manufacturer name, make, model, type) in the practitioner's notes.; Supplier-prepared statements, physician attestations, and the practitioner's order do not by themselves provide sufficient documentation of medical necessity even if signed; the medical record must contain corroborating information, and records from suppliers/healthcare professionals with a financial interest in the claim outcome are not sufficient by themselves.; Treating practitioner is defined as a physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist; a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered the treating practitioner for ordering purposes.
What does Aetna exclude for Lower Limb Prostheses?
Policy exclusions and limitations: A user-adjustable heel height feature on a prosthetic foot is NOT medically necessary.; Repair or replacement of a foot cover for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Test (diagnostic) sockets for immediate post-surgical or early-fitted (immediate) prostheses are NOT medically necessary.; Socket replacement codes are duplicative and NOT medically necessary when entire prosthesis components (e.g., feet, knees) are billed with a socket replacement code (i.e., socket replacement codes must not be used when replacing an entire prosthesis).; Items billed for replacement that are still under manufacturer warranty are NOT medically necessary.; Prosthetic donning sleeve is NOT medically necessary.; Passive/restorative devices (silicone devices) to make the limb lifelike are considered cosmetic (not covered).; Custom-shaped prosthetic covers are considered cosmetic unless medical function is documented with documentation of medical need (custom-made prosthetic covers are typically foam, cosmetically shaped).; Silver-impregnated garments (shrinkers, socks, sheaths) are NOT medically necessary due to insufficient evidence of superiority over standard garments.; Donning tubes or devices for applying a compression garment are NOT medically necessary.; Push-button rotation device allowing the user to rotate the prosthesis between the socket and the knee/shin/foot region is considered a convenience item (not covered).; Gaitor sealing sleeves are considered a convenience/cosmetic item (not covered).; 3-D printed, CAD-CAM, or similar prosthetic covers are considered cosmetic (not covered).; Duplication or upgrade of a functional prosthesis is NOT medically necessary.; A lower limb prosthesis for functional level 0 is NOT medically necessary.; Otto Bock Kenevo microprocessor-controlled knee for functional level 3 or above is NOT medically necessary.; Prosthetic devices/components primarily for cosmesis are NOT medically necessary.; Prosthetics used for activities other than normal daily living, including leisure/sporting activities (e.g., skiing, swimming), are NOT medically necessary.; Repair or replacement of a prosthesis for appearance, comfort, convenience, or individual abuse/misuse/neglect is NOT medically necessary.; Repair or replacement of parts of a duplicate prosthesis is NOT medically necessary.; Test sockets for an immediate prosthesis are NOT medically necessary.; Water prosthesis (designed for showering or swimming) is NOT medically necessary.; Adjustable click prostheses (e.g., Revo, RevoFit, Boa click systems) are experimental, investigational, or unproven.; Protective cover for microprocessor knees (e.g., C-leg Protector or similar), Bionic Protector for Rheo, UNYQ Prosthetic Covers, Limb-Art Covers (or similar), and 3-D printed covers are experimental, investigational, or unproven.; DAW Sure Stance Knee is experimental, investigational, or unproven.; Endo-skeletal above-knee positioning device allowing 360-degree rotation and locking the endo-skeletal prosthetic knee/foot in neutral position (predicate: Ottobock 4R57 Rotation Adapter) is experimental, investigational, or unproven.; HiFi Interface System (HiFi Socket) is experimental, investigational, or unproven.; Lower limb prostheses for all other indications (not listed as medically necessary) are experimental, investigational, or unproven.; Microprocessor-controlled leg prostheses for gait management in spinal cord injury are experimental, investigational, or unproven.; Osseointegrated lower limb prosthetic devices (with or without microprocessor control) are experimental, investigational, or unproven.; Ossur Pivot Foot is experimental, investigational, or unproven.; Ossur Symbiotic Leg is experimental, investigational, or unproven.; Otto Bock Kenevo microprocessor-controlled knee for members with functional level 2 or below is experimental, investigational, or unproven.; Powered ankle (addition, endoskeletal ankle-foot or ankle system, power assist, includes motor) is experimental, investigational, or unproven.; Robotic lower body exoskeleton suits (e.g., ReWalk, Argo Medical Technologies) are experimental, investigational, or unproven.; Otto Bock Genium knee system is NOT a covered item because it is not PDAC verified (billing it would be incorrect coding/unbundling).; Warranties/guarantees beyond the base warranty included in the device are NOT a medical benefit; additional warranties/guarantees beyond the included base or manufacturer warranty are considered non-medically-necessary convenience items.; Evaluation of the member, measurement, casting, and fitting/adjustments of the prosthesis are included in the prosthesis allowance and are not separately payable.; CAD-CAM technology for prosthesis fabrication is included in the allowance and is not separately payable.; For powered base items (containing a power source/battery), all necessary batteries and battery chargers are included at the time the base item is billed; batteries or chargers billed concurrently are not separately payable.; Foot covers (foot shells) are included in the prosthetic foot reimbursement and are not separately payable.; Except for items with specific HCPCS codes, there is no separate billing/payment for a component or feature of a microprocessor-controlled knee, including real-time gait analysis, continuous gait assessment, and electronically controlled static stance regulator. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0578 — Lower Limb Prostheses

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0578 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.