Orthotics and Prosthetics
Overview
Orthotic and prosthetic devices are used to support weak body parts, replace body parts, or restore ambulation. Orthoses support weak body parts and are considered medically necessary for the treatment of musculoskeletal deformity or injury, neuromuscular disorders, and chronic pain. Prostheses replace body parts or restore ambulation and are considered medically necessary for the treatment of amputation or congenital birth defect impacting a limb.
Eligible Providers
The following providers may provide orthotics and prosthetics:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.
Eligible Members
Orthotic and prosthetic devices are covered for all eligible Medical Assistance and MinnesotaCare members.
Covered Services
MHCP covers orthotic and prosthetic devices, supplies, and services that are medically necessary and prescribed by a physician or licensed health care prescriber who has authority in Minnesota to prescribe orthoses and prostheses, including devices customized to the member’s everyday needs. Members must be appropriately examined, fitted, and trained by an orthotist or prosthetist before using their device and requesting authorization, if applicable. MHCP covers an additional device for all members for purposes of bathing or showering. For eligible members, MHCP also covers a recreational device for purposes of performing physical activities including, but not limited to, running, biking, swimming, and maximizing the member’s limb function.
When providing orthotics and prosthetics, providers must:
Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements, billing frequencies, and quantity limits by HCPCS code. The quantity limits reflected on the Medical Supply Coverage Guide represent the quantity limit per limb per device.
Orthoses
Evaluation and Management
Evaluation of the member’s condition and functional ability is required. For members with existing orthoses, for whom a similar replacement is requested, evaluation can be based on the member’s history and current condition. For members for whom a first orthosis is requested or for whom a significantly different orthotic is requested, evaluation must be based on clinical observation.
Evaluations must be performed by a professional certified by the American Board of Certification in Orthotics and Prosthetics, or the Board of Certification in Orthotics and Prosthetics or a professional who has similar training or expertise. Document the evaluation. The evaluation must be less than 180 days old.
Medical records must include:
Use the following categories for orthotics for the spine, hip, and extremities when evaluating the member: prefabricated, custom fitted, or custom fabricated. Provide specific information about the member’s condition and the type of orthotic.
Prefabricated or off-the-shelf (OTS) orthoses are devices that are prefabricated. These devices require minimal self-adjustment. Minimal self-adjustment refers to adjustments that may be made by the member or their caregiver. These devices do not involve bending, molding, trimming, or altering beyond minimal self-adjustment. Prefabricated orthoses do not require expertise of a certified orthotist or professional who has similar training or expertise.
Custom fitted orthoses are devices that are prefabricated. These devices require modification of the prefabricated item to provide a customized fit. Custom fitted orthoses may or may not be supplied with a kit that requires assembly. Assembly of the device or installation of components in preparation of the device does not change classification from OTS to custom fitted. Classification as custom fitted requires substantial modification. Modifications must involve bending, molding, trimming, or altering beyond minimal self-adjustment. Suppliers must document the customizations of the device.
Custom fabricated orthoses are devices that are individually made for a specific member. These devices require substantial customization from castings, measurements, tracings, and imaging of the body part. Custom fabricated orthoses may involve calculations, components, and templates. Materials required may include cloth, leather, metal, plastic, and other raw materials for construction of the device. Classification as custom fabricated requires substantial modification including bending, cutting, drilling, molding, sewing, and vacuum forming the device to the member. This fitting requires expertise of a certified orthotist or professional who has similar training or expertise.
MHCP covers orthoses for the spine, hip, lower and upper limbs, cranial remolding orthoses, protective helmets, orthopedic and therapeutic footwear, and orthotic supplies. There is no separate payment for the evaluation, fitting, molding, or training of use for equipment as these services are included in the applicable HCPCS codes. The usual reasonable useful lifetime (RUL) of five years for durable medical equipment (DME) does not apply to custom fitted or custom fabricated orthotics. Refer to the Reasonable Useful Lifetime subsection of this MHCP Provider Manual section for information on subsequent new or replacement custom orthotics.
Authorization is not required for prefabricated or custom orthotic devices for everyday use and for purposes of bathing or showering, unless the individual HCPCS codes always require authorization. Authorization is required for recreational orthotics, excess quantities, and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21. Refer to the Devices for Bathing or Recreation subsection of this MHCP Provider Manual section for information on devices for purposes of bathing or showering or recreation.
Spinal Orthoses
Codes: L0112-L1499
Orthotics for the spine are considered medically necessary to:
MHCP covers one unit of prefabricated orthotics for the spine for purposes of everyday use and for bathing per calendar year without authorization. MHCP covers one custom orthotic device for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities, and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21.
Types of orthotics for the spine include cervical orthotics, thoracic-lumbar-sacral orthotics (TLSOs), sacral orthotics (SOs), lumbar orthotics (LOs), lumbar-sacral orthotics (LSOs), cervical-thoracic-lumbar-sacral orthotics (CTLSOs), cervical halo procedures, scoliosis orthotic devices, accessories, and additions.
Spinal orthotics (L1499) and additions (L0999) that are not otherwise specified require authorization if the submitted charge is more than $400. HCPCS codes L0999 and L1499 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified item.
Hip Orthoses
Codes: L1600-L1755, L2040-L2090
Orthotics for the hip are considered medically necessary to:
MHCP covers one unit of prefabricated orthotics for the hip for purposes of everyday use and for bathing per calendar year without authorization. MHCP covers one custom orthotic device for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities, and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21.
Types of orthotics for the hip include hip orthotics (HOs), Legg Perthes orthotics, and hip-knee-ankle-foot orthotics (HKAFOs).
Lower Limb Orthoses
Codes: L1810-L2038, L2106-L2136, L2999, L4350-L4631
Lower limb orthotics are considered medically necessary to:
MHCP covers two units of prefabricated orthotics per each impacted extremity per type of orthotic for purposes of everyday use and one unit for bathing per calendar year without authorization. MHCP covers one custom orthotic device per each impacted extremity per type of orthotic for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities, and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21.
Types of orthotics for the lower limb include knee orthotics (KOs), ankle-foot orthotics (AFOs), knee-ankle-foot orthotics (KAFOs), accessories, and additions. Documentation must include physician order and medical necessity for each type of orthotic dispensed.
Lower limb orthotics that are not otherwise specified (L2999) require authorization if the submitted charge is more than $400. HCPCS code L2999 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified item.
Custom-Fabricated Swing-Phase Release and Microprocessor-Controlled KAFOs (L2005, L2006)
Custom-fabricated KAFOs with automatic lock and swing-phase release (L2005) and microprocessor-controlled KAFOs (L2006) are covered with authorization if all of the following criteria are met:
Upper Limb Orthoses
Codes: L3650-L3999, L8701, L8702
Upper limb orthotics are considered medically necessary to:
MHCP covers two units of prefabricated orthotics per each impacted extremity per type of orthotic for purposes of everyday use and one unit for bathing per calendar year without authorization. MHCP covers one custom orthotic device per each impacted extremity per type of orthotic for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities, and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21.
Types of orthotics for the upper limb include shoulder orthotics (SOs), elbow orthotics (EOs), finger orthotics (FOs), elbow-wrist-hand orthotics (EWOs), wrist-hand-finger orthotics (WHFOs), wrist-hand orthotics (WHOs), shoulder-elbow-wrist-hand-finger orthotics (SEWHFOs), accessories, and additions. Documentation must include physician order and medical necessity for each type of orthotic dispensed.
Upper limb orthotics that are not otherwise specified (L3999) require authorization if the submitted charge is more than $400. HCPCS code L3999 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified item.
Custom-Fabricated Powered Upper-Extremity Assist Devices (L8701, L8702)
Custom-fabricated powered upper-extremity range-of-motion assist devices are covered with authorization if all of the following criteria are met:
Powered upper extremity assist devices are contraindicated for any of the following:
Cranial Remolding Orthoses
Code: S1040
Cranial remolding orthotics are considered medically necessary for treatment of head deformities associated with:
Up to two cranial remolding orthotics are covered without authorization for members under age 2. Authorization is required for the third and subsequent cranial remolding orthotic.
Protective Helmets
Codes: A8000-A8004
Protective helmets, including prefabricated and custom fabricated items and soft interface replacements, are considered medically necessary for members at risk of head injury due to a medical condition such as seizures or developmental disability. Most members older than 2 years old can be served with one protective helmet per year. Members younger than 2 years old may require more frequent replacements. Documentation needs to explain why a prefabricated helmet does not suffice.
Orthopedic and Therapeutic Footwear
Codes: A5500-A5501, A5503-A5507, A5510-A5513, A9283, L3000-L3595, L3600-L3649
Orthopedic footwear is considered medically necessary for treatment of structural conditions of the foot. Therapeutic footwear is considered medically necessary to prevent diabetic ulcers.
Orthopedic Footwear
Custom-made orthopedic shoes, modifications, additions, and inserts are considered medically necessary when the shoes are an integral part of the leg brace, or the member has one or more of the following:
MHCP covers two units each of orthopedic shoes and inserts per each impacted extremity per calendar year without authorization. Deluxe features of orthopedic shoes (A5508) are noncovered.
Orthopedic shoes, modifications, additions, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts. All items must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist, or prosthetist.
Therapeutic Shoes and Inserts for Diabetes
Custom-made or prefabricated therapeutic shoes, modifications, and inserts are considered medically necessary for members with diabetes and one or more of the following:
MHCP covers two units of therapeutic shoes and three units of inserts per each impacted extremity per calendar year without authorization. The member’s medical condition may impact one foot or both feet. Inserts are only covered for member-owned therapeutic shoes.
Therapeutic shoes, modifications, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of diabetic shoes and inserts. All items must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist, or prosthetist.
Foot Pressure Off-Loading Devices (A9283)
Foot pressure off-loading devices are considered medically necessary for members with existing pressure ulcers of the foot.
Supplies for Orthoses
Codes: L0970-L0984, L2180-L2861
MHCP covers supplies for orthotic devices. Supplies are covered if they are medically necessary and are required for the functioning of the orthotic device. Providers must document medical necessity and that the supply or replacement item is required for device functioning. The following list of supplies does not include all supplies covered by MHCP. The reasonable useful lifetime (RUL) for durable medical equipment (DME) applies to orthotic supplies. Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements, billing frequencies, and quantity limits by HCPCS code. Refer to the Replacement Orthoses Components subsection of this MHCP Provider Manual section for information on replacement parts for orthotic devices.
Corsets for spinal orthotics are used to adjust tension and close the device. Some corsets use corset fronts (L0970, L0972), which attach to the back of the device. Full corsets (L0974, L0976) have a fabric body and closure, usually on the front of the device.
Auxiliary crutch extensions (L0978) use a pad under the armpit to hold most of the member’s weight over the double uprights. Peroneal straps (L0980) are used with devices that tend to migrate upward as the member engages in ADLs. The straps connect to the bottom of the spinal orthotic to ensure the device does not move upward. Stocking supporter grips (L0982) attach to the top of stockings and the bottom of support garments to hold stockings in place.
Protective body socks (L0984) are prefabricated garments composed of soft fabric and used under spinal orthotics. MHCP covers two units per member-owned orthotic device per year when the original item no longer functions. Authorization is required for excess quantities.
Joints for limited ankle motion (L2200) are an addition to AFOs that limit ankle motion. This may involve molding a block to the device interface or otherwise manipulating the device to limit movement.
Dorsiflexion assist (L2210) and dorsiflexion and plantar flexion assist (L2220) involve the application of a spring-loaded cylinder on the orthotic device’s ankle portion that works against a piston rod on the foot portion. The spring tension assists or resists flexion of the foot. Some items, including caliper plates (L2240), stirrup plates (L2230), and stirrups (L2260, L2265), may be attached to an existing device.
Rocker bottoms for total contact custom-fabricated AFOs (L2232) involve customization of an existing device by adding a specialized sole structure. These items promote a more natural gait by distributing pressure more evenly in the lower extremity.
Varus or valgus correction, including straps (L2270) and plastic modification (L2275), involves treatment of joint inversion or eversion by an AFO with a bar and t-strap on either the lateral or medial side of the device. Molded inner boots (L2280) are rigid protective coverings for the member’s ankle and foot. They usually are vacuum formed with a plaster mold of the member’s ankle and foot and composed of polypropylene or similar material.
Abduction bars (L2300, L2310) are used to maintain abduction during healing. Molded (L2330) and nonmolded (L2320) lacers are cuff-like supports that fit around the member’s calf area. They are used to address functional or structural impairments in the lower extremity. Anterior swing bands (L2335) are additions for use of attachment to devices. Pretibial shells (L2340) are additions that are molded and support the member’s shin area. Extended steel shanks (L2360) are used for insertion between shoe soles to ensure more rigidity to the shoe. Patten bottoms (L2370) are attachments to KAFOs that transfer weight to the member’s device and upper leg.
Torsion control, including ankle joint and half solid stirrups (L2375) and straight knee joints (L2380), involves treatment of knee instability. These items stabilize the knee joint by managing rotational forces of the knee. Heavy-duty straight knee joints (L2385) are 180-degree stop unicentric joints for use with KOs and KAFOs. Polycentric knee joints (L2387) ensure stability at full extension and easy movement during swing phase for custom KAFOs. Offset knee joints (L2390, L2395) are additions that enhance knee stability.
Suspension sleeves (L2397) are sometimes used with lower limb orthotic devices to secure the device in place and enhance mobility and device effectiveness. These devices feature a liner that makes a nonslip suction-type contact to the member’s skin.
Knee joint additions are used for treatment of knee instability. Drop locks (L2405) involve the member lifting a locking mechanism to drop the device from the fixed walking position. Lift loops (L2492) are gripping devices that the member uses to raise the locking ring of the drop lock mechanism. Some additions have more advanced properties, including integrated release mechanism (L2415), disc or dial lock for adjustable knee flexion (L2425), and ratchet lock for active and progressive knee extension (L2430).
Weight bearing additions (L2500 to L2550) are used for distributing weight evenly to enhance comfort and fit. Pelvic control hip joints (L2570 to L2628) are used for treatment of hip instability. These joints are specialized to aid in pelvic control. Bands and belts (L2630, L2640) are secured to the device by hip joints. Gluteal pads (L2650) are pads that provide support to the gluteal area.
Thoracic bands (L2660) are for use with bilateral HKAFOs. Bands, including those with paraspinal uprights (L2670) and lateral uprights (L2680), provide control of the torso and spinal alignment.
Fracture socks, including tibial (L2840) and femoral (L2850) length, are highly elastic and may be applied to certain types of closed fractures of the lower extremity. Socks are usually used concurrently with a rigid orthotic device.
Concentric adjustable torsion style mechanisms (L2861) for custom devices are components that incorporate power assist. The add-on component is attached to the ankle or knee component of a custom device and adds the ability to assist or resist as medically necessary.
Prostheses
Evaluation and Management
Evaluation of the member’s condition and functional ability is required. For members with existing prostheses, for whom a similar replacement is requested, evaluation can be based on the member’s history and current condition. For members for whom a first prosthesis is requested or for whom a significantly different prosthetic is requested, evaluation must be based on clinical observation.
Evaluations must be performed by a professional certified by the American Board of Certification in Orthotics and Prosthetics, or the Board of Certification in Orthotics and Prosthetics or a professional who has similar training or expertise. Document the evaluation. The evaluation must be less than 180 days old.
Medical records must include:
MHCP covers prostheses for the lower and upper limbs, breasts, eyes, and face, medical wigs, and prosthetic supplies. There is no separate payment for the evaluation, fitting, molding, or training of use for equipment as these services are included in the applicable HCPCS codes. The usual RUL of five years for DME does not apply to prosthetics. Refer to the Reasonable Useful Lifetime subsection of this MHCP Provider Manual section for information on subsequent new or replacement prosthetics.
Authorization is not required for initial prosthetic devices for everyday use and for purposes of bathing or showering or for bilateral amputees, unless the individual HCPCS codes always require authorization. Authorization is required for recreational prosthetics and subsequent new prosthetics for any purpose. Refer to the Devices for Bathing or Recreation subsection of his MHCP Provider Manual section for information on devices for purposes of bathing or showering or recreation.
Lower Limb Prostheses
Codes: L5000-L5999
Lower limb prosthetics are considered medically necessary for treatment of amputation or congenital birth defects in lower extremities.
Medical records must include:
Use the following functional levels in the evaluation. Provide specific information about the member’s ambulation history, performance, and ADLs to support assignment of a member to a functional level.
Members whose function level is 0 are not eligible for lower limb prosthetics as the device would not enhance mobility or quality of life. Providers must use modifiers K1, K2, K3, and K4 as appropriate for billing lower limb prosthetics. Members must meet coverage criteria for the applicable HCPCS codes based on the member’s assigned functional level.
Lower limb prosthetics that are not otherwise specified (L5999) require authorization if the submitted charge is more than $400. HCPCS code L5999 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified item.
Review the following categories of lower limb prosthetics for HCPCS code descriptions and required member functional level for prosthetic ankles, feet, hips, knees, and other devices.
Feet and Ankles
Knees
Polycentric Hip Joint (L5961)
A pneumatic or hydraulic polycentric hip joint (L5961) may be medically necessary for members whose functional level is 3 or above.
Vacuum Suspension Systems (L5781, L5782)
Vacuum suspension systems (L5781 or L5782) may be medically necessary for members whose functional level is 2 or above.
Osseointegrated External Prosthetic Connectors (L5991)
Osseointegrated ext ernal prosthetic connectors, components of bone-anchored prosthetic devices, are covered with authorization if all of the following criteria are met:
Osseointegrated external prosthetic connectors are contraindicated for any of the following:
Complete skeletal growth is defined as the finding of generally closed epiphyseal zones through X-rays. Atypical skeletal anatomy includes but is not limited to conditions which are not amenable to device insertion, development anomalies, and skeletal dimensions outside of the defined interval.
Upper Limb Prostheses
Codes: L6000-L7259, L7400-L7499
Upper limb prosthetics are considered medically necessary for treatment of amputation or congenital birth defects in upper extremities.
Medical records must include:
Use the following categories for upper limb prosthetics when evaluating the member. Provide specific information about the member’s history, performance, and ADLs to support assignment of a particular device.
Passive Prostheses
Passive prostheses do not move on their own, are lightweight, and enhance the member’s condition by stabilizing or carrying objects. A passive upper extremity prosthetic is covered for members if all of the following criteria are met:
Body-Powered Prostheses
Body-powered prostheses use body movements to control the device. A body-powered upper extremity prosthetic is covered for members if all of the following criteria are met:
Myoelectric or Hybrid Prostheses
Myoelectric prostheses use electromyographic signals in muscle contractions to control the device. A myoelectric or hybrid upper extremity prosthetic is covered for members if all of the following criteria are met:
Upper limb prosthetics that are not otherwise specified (L7499) require authorization if the submitted charge is more than $400. HCPCS code L7499 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified item.
Breast Prostheses
Codes: L8000-L8002, L8010, L8015, L8020, L8030-L8033, L8035, L8039
Breast prosthetics are covered for members who have had a mastectomy or other conditions that result in absence or defect of the breast.
Medical records must include:
Use the following HCPCS code descriptions when evaluating the member.
Mastectomy bras without integrated prosthesis form (L8000) and with integrated prosthesis form (L8001 and L8002) come in various materials and sizes to fit patients who have undergone a mastectomy. Authorization is not required for mastectomy bras. MHCP covers only one breast prosthetic per side for members who have undergone bilateral mastectomies.
A mastectomy sleeve (L8010) is covered for members with post-mastectomy lymphedema.
An external breast prosthesis garment (L8015) is covered for the postoperative period before a permanent breast prosthetic, or as an alternative to a mastectomy bra and breast prosthetic.
A mastectomy bra (L8000) is covered for members with mastectomy form (L8020) or silicone breast prosthetic without integrated adhesive (L8030) when the pocket of the bra is used to hold the prosthetic.
MHCP covers silicone breast prosthetics with integrated adhesives (L8031), prefabricated and custom nipple prosthetics (L8032 and L8033), and custom breast prosthetics (L8035). Authorization is always required for custom breast (L8035) and nipple (L8033) prosthetics and not otherwise specified breast prosthetics (L8039). Documentation must clearly articulate why prefabricated prosthetics do not satisfy the needs of the member. HCPCS code L8039 should only be used when a breast prosthetic is not described by a more specific HCPCS code (L8000 to L8035).
Eye and Iris Prostheses
Codes: 66683, C1839, V2623-V2629
Eye and iris prosthetics are covered for members who have absence, defect, shrinkage, or specific conditions of the eyes or iris.
Medical records must include:
Authorization is not required for eye prosthetics. Authorization is only required for subsequent new eye prosthetics if the current prosthetic device is less than five years old. Authorization is required for iris prosthetics.
Use the following categories and HCPCS code descriptions when evaluating the member.
Eye Prostheses
Eye prostheses are covered for members with absence or shrinkage of an eye due to disease, congenital defect of eye, surgery, or trauma.
Use the following HCPCS code descriptions when evaluating the member.
An ocular prosthetic (V2623) is an artificial eye that fits over an orbital implant and under the eyelids that produces the appearance of a normal human eye. Eye prosthetics assist in maintaining the internal orbital eye structures by filling in the void created by the missing natural eye.
Polishing and resurfacing (V2624) is covered for members without authorization two times per calendar year.
One enlargement (V2625) or reduction (V2626) is covered without authorization. Additional enlargements or reductions are rarely medically necessary and are therefore covered only when there is documentation in the medical record which supports medical necessity. This information must be made available to DHS or its authorized agent upon request.
MHCP covers scleral cover shells (V2627) and the fabrication and fitting of ocular conformers (V2628). Authorization is always required for not otherwise specified eye prosthetics (V2629). Documentation must clearly articulate why prefabricated prosthetics do not satisfy the needs of the member. HCPCS code V2629 should only be used when an eye prosthetic is not described by a more specific HCPCS code (V2623 to V2628).
Iris Prostheses
Iris prosthetics compensate for a defect of the iris of an eye. An iris prosthetic (C1839) is considered medically necessary for treatment of aniridia for members three years of age and older. Authorization is always required for iris prosthetics and device implantation. The implantation is described by CPT code 66683. Iris prosthetics are not covered for members with certain eye conditions, such as uncontrolled inflammation, severe chronic uveitis, microphthalmos, untreated retinal detachment, untreated chronic glaucoma, rubella cataract, rubeosis of the iris, proliferative diabetic retinopathy, Stargardt’s retinopathy, or intraocular infections, or in pregnant women.
Facial Prostheses
Codes: L8040-L8049
Facial prosthetics are covered for members with loss or absence of facial tissue due to disease, congenital defect, surgery, or trauma.
Medical records must include:
Authorization is not required for facial prosthetics. Authorization is only required for subsequent new facial prosthetics if the current prosthetic device is less than five years old.
Use the following HCPCS code descriptions when evaluating the member.
A nasal prosthesis (L8040) is a removable superficial prosthesis, which restores all or part of the nose. It may include the nasal septum.
A midfacial prosthesis (L8041) is a removable superficial prosthesis, which restores part or all of the nose plus significant adjacent facial tissue but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue includes one or more of soft tissue of the cheek, upper lip, or forehead.
An orbital prosthesis (L8042) is a removable superficial prosthesis, which restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. This code does not include the ocular prosthesis component.
An upper facial prosthesis (L8043) is a removable superficial prosthesis, which restores the orbit plus significant adjacent facial tissue but does not include the nose or any intraoral maxillary component. Adjacent facial tissue includes one or more of soft tissue of the cheek or forehead. This code does not include the ocular prosthesis component.
A hemi-facial prosthesis (L8044) is a removable superficial prosthesis, which restores part or all of the nose plus the orbit plus significant adjacent facial tissue but does not include any intraoral maxillary component. This code does not include the ocular prosthesis component.
An auricular prosthesis (L8045) is a removable superficial prosthesis, which restores all or part of the ear.
A partial facial prosthesis (L8046) is a removable superficial prosthesis which restores a portion of the face, but which does not specifically involve the nose, orbit, or ear.
A nasal septal prosthesis (L8047) is a removable prosthesis, which closes a hole in the nasal septum but does not include superficial nasal tissue.
Authorization is always required for unspecified maxillofacial prosthetics (L8048). HCPCS code L8048 should only be used when a facial prosthetic is not described by a more specific HCPCS code (L8040 to L8047) or for components used to attach the facial prosthetic to a bone-anchored implant or to an internal prosthesis. HCPCS code L8048 code should not be used for implanted prosthesis-anchoring components. Medically necessary modifications and repairs are covered under L8048 for materials used and L8049 for labor components. MHCP allows up to six units of L8049 per day.
Scalp Hair Prostheses
Code: A9282
Scalp hair prostheses are considered medically necessary for treatment of medical conditions that result in hair loss. One medical wig is covered per calendar year with an annual limit of $1,000.
Supplies for Prostheses
Codes: L5618-L5707, L5962, L5964, L5966, L6031, L6883-L6885, L8400-L8499
MHCP covers supplies for prosthetic devices. Supplies include sockets, test sockets, socket inserts, liners, suspension sleeves, sheaths, shrinkers, socks, and accessories. Supplies are covered if they are medically necessary and are required for functioning of the prosthetic device. Providers must document medical necessity and that the supply or replacement item is required for device functioning. The following list of supplies does not include all supplies covered by MHCP. The reasonable useful lifetime (RUL) for durable medical equipment (DME) applies to prosthetic supplies. Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements, billing frequencies, and quantity limits by HCPCS code.
Test sockets (L5618 to L5628, L6029, L6680 to L6684) are used to determine optimal fit and interface between the member’s skin at the residual limb and the material of the device. Multiple test sockets may be required to determine optimal fit as the residual limb stabilizes following amputation. MHCP covers two test sockets per prosthetic device. Authorization is required for excess quantities.
Sockets (L5629 to L5632, L5634, L5636 to L5640, L5642 to L5653) are the part of the prosthetic device that fits around the residual limb and to which components and additions are attached. The socket must be precisely measured to ensure proper control and stability. Designs and features of sockets vary. Some socket designs include a flexible inner socket with an external frame or strapping (L5643, L5645, L5651). Some sockets have a release button to assist in removal of the prosthetic device. MHCP covers one socket per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
Total contact sockets (L5637, L5650) fully interface with the residual limb and allow more surface area to bear weight against the prosthetic device. Air cushion sockets (L5646, L5648) are used for active ambulators and running. Suction sockets (L5647) usually have a silicone interface that creates a vacuum from natural properties as the socket is worn and weight placed against the prosthetic device. Ischial containment sockets (L5649) are sockets for above-knee amputations that contain the ischial tuberosity within the socket.
Socket inserts (L5654 to L5658, L5661, L5665) serve as the interface between the residual limb and the prosthetic device. Socket inserts aid in the protection of fragile skin of the residual limb while compensating for changes in limb volume. Some prosthetic devices fit comfortably without use of a socket insert. MHCP covers one socket insert per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
Liners (L5673, L5679) are soft sleeves that are worn over the residual limb and inside the prosthetic socket. Liners protect the residual limb, support suspension, increase comfort, and reduce the risk of skin irritation. MHCP covers two liners per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
Molded distal cushions (L5668) are additions to liners that are fabricated from an impression of the residual stump.
Thigh lacers (L5680, L5682) are corset-like cuffs that are attached to lower limb prosthetic devices, usually by two vertical sidebars to form a suspension system. Thigh lacers are for members who have undergone below-knee amputations and cannot tolerate full-contact pressure on their residual limb.
Suspension sleeves (L5685) are used to hold the prosthetic device in place, distribute pressure, and reduce friction, rotation, and volume. Suspension locking mechanisms (L5671) use lanyards or pins that screw into the end of the socket to connect to the residual limb. Cuff suspension (L5666) allows the lower limb prosthetic device to make full contact with the residual limb by ensuring the integrity of the entire system. Cuffs are gripping devices that hold the residual limb below the knee.
Single-axis knee joints (L5676) act as a door-and-hinge device that allows one-speed ambulation, is free swinging, and does not allow stance control. Polycentric knee joints (L5677) have multiple rotational axes that include four points of rotation attached by a linkage bar. They are stable in early stance and easy to flex in swing phase.
Waist belts (L5688, L5690) are used to provide suspension support, primarily for members who have weak musculature or cannot tolerate other forms of suspension. Pelvic control belts (L5692, L5694) are used to maintain proper gait mechanics for members with above-knee prosthetics. Pelvic control sleeve suspension (L5695) is pulled over the residual limb and extends over the pelvis. Pelvic joints (L5696) are composed of single and multiple axes and are mounted in the front of the prosthetic device. They provide flexibility at the hip and allow ambulation. Pelvic bands (L5697) are broad bands or wrappings worn around the waist and from which the prosthetic device is attached.
Molded-to-patient-model replacement sockets (L5700 to L5703, L6031, L6883 to L6885) are covered for member-owned prosthetic devices when the original item no longer functions. Documentation must clearly articulate why nonmolded-to-patient sockets do not satisfy the needs of the member. Authorization is always required.
Custom-shaped protective covers (L5704 to L5707) are protective coverings for prosthetic devices that are manufactured to match the length, size, and thickness of the member’s lost limb and are usually constructed to resemble human skin. Protective covers allow protection, shaping, and weatherproofing. Protective outer surface covering systems (L5962, L5964, L5966) are specialized coverings that are used against unusually harsh environments. Protective outer surface covering systems are not for use in typical environments. Protective coverings are noncosmetic. MHCP covers one unit per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
Textile products include sheaths, shrinkers, and socks. Sheaths (L8400, L8410, L8415, L8417) are protective garments that are worn against skin beneath a sock (L8420, L8430, L8435, L8470, L8480, L8485). Sheaths are used to reduce friction and provide comfort and moisture management. Shrinkers (L8440, L8460, L8465) are used to reduce swelling, shape the limb, and prepare the limb for prosthetic fitting.
Authorization is always required for unlisted procedures for miscellaneous prosthetic services (L8499). HCPCS code L8499 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified procedure or service. Providers cannot bill noncovered services under miscellaneous HCPCS code L8499 or any other miscellaneous code. Refer to the Noncovered Services section of this MHCP Provider Manual section for information on which items and services are noncovered by MHCP.
Batteries and Chargers
Codes: L7360, L7362, L7364, L7366-L7368
MHCP covers powered prosthetics, batteries, and chargers. Powered-prosthetic base codes are items that contain the power source. When a base code is dispensed, MHCP considers all batteries (L7360, L7364, L7367) and chargers (L7362, L7366, L7368) as included in the payment for the base item. There is no separate payment for these items billed concurrently with powered prosthetics.
Payment for batteries and chargers is included in the payment for these base codes:
Base Codes | Battery and Charger Codes |
L2005, L2006, L3904, L5781, L5782, L5856, L5857, L5858, L5859, L5973, L6026, L6700, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L8701, L8702 | L7360, L7362, L7364, L7366, L7367, L7368 |
Many powered prosthetic base codes are used concurrently with add-ons that derive power from the power source. When an add-on to a base code is dispensed, MHCP considers all batteries (L7360, L7364, L7367) and chargers (L7362, L7366, L7368) as included in the payment for the item. There is no separate payment for these items billed concurrently with powered prosthetic add-ons.
Payment for batteries and chargers is included in the payment for these add-on codes and the appropriate base code:
Add-On Codes | Base Codes | Battery and Charger Codes |
L5827, L5969, L6621, L6638, L6646, L6648, L6715, L6880, L6881, L6882, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259 | L5781, L5782, L5856, L5857, L5858, L5859, L5973, L6026, L6700, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975 | L7360, L7362, L7364, L7366, L7367, L7368 |
MHCP pays for one battery and charger annually only when the original item no longer functions.
Devices for Bathing or Recreation
Devices for purposes of bathing or showering and for purposes of recreation are covered. Recreational devices are intended for performing physical activities including, but not limited to, running, biking, swimming, and maximizing the member’s limb function. Members whose functional level is 2 or above are eligible for recreational prosthetics. Authorization is required for devices for recreation. Use modifier U2 for billing. Authorization is not required for orthotics or initial prosthetics for bathing or showering. Bathing devices are intended for member use while bathing, cleaning, or showering. Members whose functional level is 1 or above are eligible for bathing prosthetics. Use modifier U1 for billing. Bathing devices only require authorization if they are the member’s third device. It is the expectation of MHCP that devices for bathing or showering are nonelectronic and made from the least costly items and waterproof materials.
Recreational devices are covered with authorization if all of the following criteria are met:
Repairs and Replacements
Codes: L4000-L4210, L7510, L7520
Repairs to devices are covered without authorization with the following exceptions:
Replacements for a device or parts of a device are covered, without regard to useful lifetime restrictions, if ordered by an eligible provider because:
Bill repairs with the appropriate HCPCS code and modifier RB. Bill replacements with the appropriate HCPCS code and modifier RA.
Bill labor and material costs for miscellaneous minor parts using one of the following HCPCS codes:
One unit of service for HCPCS codes L4205 and L7520 represents 15 minutes of labor. One unit of service for HCPCS codes L4210 and L7510 represents one miscellaneous minor part.
HCPCS codes L4210 and L7510 should only be used for repair or replacement of minor parts without an applicable HCPCS code. Miscellaneous minor parts are covered if they are medically necessary and are required for functioning of the device. Documentation must include description of the item, manufacturer name, product name, model number, confirmation of medical necessity, and detailed pricing information. Miscellaneous minor parts that are cut or separated from a larger unit must have documentation explaining how the item’s price was determined from the original unit. Providers must use common units of measurement such as square inches when it is possible.
Replacement Orthoses Components
MHCP pays for replacement parts when the original item is no longer functional. Replacement of certain worn components of orthotic devices is not considered repair. Authorization is not required for replacement parts described by the following HCPCS codes, unless requesting quantities over the MHCP quantity limit.
L4000 | L4030 | L4055 | L4090 |
L4002 | L4040 | L4060 | L4100 |
L4010 | L4045 | L4070 | L4110 |
L4020 | L4050 | L4080 | L4130 |
Reasonable Useful Lifetime
The usual reasonable useful lifetime (RUL) of five years for durable medical equipment DME does not apply to prosthetics or custom orthotics. Custom orthotics include devices that are custom fabricated, or custom fitted to a specific member based on their unique physical condition. MHCP covers medically necessary repairs and replacements for parts and devices. Members cannot automatically obtain a new device if the original is still in working order.
MHCP pays for the initial prosthetic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational prosthetics and subsequent new or replacement prosthetics for any purpose. MHCP pays for custom orthotic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational orthotics and subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or older or if the current orthotic is less than one year old for members under age 21.
Replacement Orthoses and Prostheses Requirements Chart
Refer to the Replacement orthoses and prostheses requirements chart to review MHCP requirements for replacement devices by type of orthotic or prosthetic device.
Replacement orthoses and prostheses requirements
Type of Device | Quantity Limits | Authorization Requirements |
Prefabricated spinal and hip orthoses | Everyday use (no U modifier): 1 unit per year Bathing (U1): 1 unit per year Recreation (U2): 1 unit per year | Recreational orthoses Quantities that exceed MHCP quantity limits |
Prefabricated lower and upper extremity orthoses | Everyday use (no U modifier): 2 units per limb per year per type of orthosis Bathing (U1): 1 unit per limb per year per type of orthosis Recreation (U2): 1 unit per limb per year | Recreational orthoses Quantities that exceed MHCP quantity limits |
Custom fitted or custom fabricated spinal and hip orthoses | Everyday use (no U modifier): 1 device (combination of L HCPCS codes) Bathing (U1): 1 device Recreation (U2): 1 device | Recreational orthoses Members under age 21: Replacement orthoses if the current device is less than 1 year old Members age 21 and older: Replacement orthoses if the current device is less than 3 years old |
Custom fitted or custom fabricated lower and upper extremity orthoses | Everyday use (no U modifier): 1 device per limb per type of orthosis (combination of L HCPCS codes) Bathing (U1): 1 device per limb per type of orthosis Recreation (U2): 1 device per limb | Recreational orthoses Members under age 21: Replacement orthoses if the current device is less than 1 year old Members age 21 and older: Replacement orthoses if the current device is less than 3 years old |
Lower and upper extremity prostheses | Everyday use (no U modifier): 1 device per limb (combination of L HCPCS codes) Bathing (U1): 1 device per limb Recreation (U2): 1 device per limb | Recreational prostheses Replacement prostheses for any purpose (no U modifier, U1, or U2) |
Eye and facial prostheses | Eyes: 1 unit per side Facial: 1 unit | Replacement prostheses if the current device is less than 5 years old |
Noncovered Services
MHCP does not cover the following:
Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.
Authorization
Authorization is required for the following:
Authorization is not required for immediate postsurgical or early fittings (L5400 to L5460, L6037, L6380 to L6388), initial prostheses (L5500, L5505), preparatory prostheses (L5510 to L5600, L6580 to L6590), or the first two test sockets (L5618 to L5628, L6029, L6680 to L6684). The device must be guaranteed to fit the member for a minimum of period of 90 days. Any modifications to a device or its parts are noncovered for 90 days after the date of delivery.
Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements, billing frequencies, and quantity limits by HCPCS code. The quantity limits reflected on the Medical Supply Coverage Guide represent the quantity limit per limb per device.
Submit authorization requests through MN–ITS Authorization Request 278. Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the Medical Review Agent. Write the MN–ITS authorization request number on each page of each document. Review the Authorization section of the MHCP Provider Manual for more information about authorization requests.
Billing
Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.
Bill orthotic and prosthetic devices using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user manual for claim instructions.
Definitions
Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.
Body-powered prosthetic: Upper body prosthetic that uses body movements to control the device. These protheses typically feature a cable and hardness, can withstand rugged environments, are lightweight, and used for performing heavy-duty activities and manual labor. Body-powered prostheses typically feature a cable and harness.
Custom-fabricated: Item that is made for a specific member from his or her individual measurements or pattern, starting with basic materials such as plastic, metal, leather, etc.
K-level: Medicare-assigned rating system to indicate an amputee’s rehabilitation potential.
Myoelectric or hybrid prosthetic: Upper body prosthetic that uses electromyographic signals in muscle contractions to control the device. The member’s physical movements in the residual limb generate electrical signals, which electrodes then send to a controller, thereby triggering the device to correspond with the member’s intended movement. Hybrid systems use a combination of body and external power control components.
Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body part or for restricting or eliminating motion in a diseased or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded A4466.
Passive prosthetic: Upper body prosthetic that does not move on its own. These prostheses are lightweight, may resemble the missing limb, and enhance the member’s condition by stabilizing or carrying objects.
Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.
Prefabricated or off-the-shelf (OTS): Item that is not made for a specific member’s specifications. They may be adjusted or altered to meet the member’s needs but are not made specifically for the member. An item that is assembled solely from prefabricated components is considered prefabricated.
Prosthetic: A device that is used for the purpose of replacing missing limbs to help individuals regain functionality and independence.
Legal References
Minnesota Statutes, 62Q.661 (Coverage for Orthotic and Prosthetic Devices)
Minnesota Statutes, 256B.0659, subdivision 2 (Orthotic and Prosthetic Devices, Supplies, and Services)
Code of Federal Regulations, title 42, Section 414.202 (3) (Prosthetic Definition)
Code of Federal Regulations, title 42, Section 414.210 (f) (Reasonable Useful Lifetime)
Centers for Medicare & Medicaid Services (CMS) Policy Article A52496 (Lower Limb Prostheses)
CMS Policy Article A55426 (Standard Documentation Requirements)
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