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

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

Service: DME-Upper and Lower Limb Prostheses

PUM 250-0026-1709

Medical Guideline Committee Approval Q2-06/2025 Effective Date 01/01/2026

Coverage for Prosthesis varies across plans. Refer to the member’s benefit plan document for coverage details.

Description:

This guideline addresses prosthetic devices-fabricated items designed as replacements for missing body parts. There are many different prosthetic upper and lower limb designs available. The choice of prosthetic design depends upon the level of amputation as well as the individual’s physical condition, ability to ambulate safely, expected functional activity level, and benefit coverage. Design options include simple prosthetics that function optimally at one walking cadence, heavier hydraulic controlled devices that allow variation of walking cadence, and microprocessor-controlled devices. Microprocessor- controlled/computer-controlled/myoelectric devices are considered a type of power enhancement/controlled device.

Indications of Coverage:

A. GENERAL CRITERIA REQUIRED FOR A PROSTHETIC DEVICE

1. Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe prosthetics according to State law; and
2. The prosthetic will significantly improve or restore physical functions required for mobility related activities of daily living (ADL’s); and
3. The members participating physician or licensed health care practitioner has determined that the prosthesis will allow the member to perform ADLs based on physical examination of the member; and
4. The prosthesis is provided within six months of the date of prescription; and
5. The prosthetic services are performed by a duly licensed and /or certified, if applicable, prosthetic provider. (All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided); and

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6. The services provided are of the complexity and nature to required being provided by a licensed or certified professional prosthetist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. (Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state laws, as physicians are not licensed as prosthetists); and

7. The certified professional prosthetist must be in good standing with one or more of the following: a. American Board for Certification (orthotics, prosthetics, pedorthics); or
   b. Board of Certification/Accreditation (prosthetics, orthotics) (BOC); or
   c. Licensed by the state in which services are provided (where legally required).

   Medical Necessity for a prosthetic appliance is based on an individual’s functional ability when using the prosthetic. Functional ability is based on the following classification levels:

   Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance their quality of life or mobility.

   Level 1: Has the ability or potential to use prosthesis for transfers or ambulation on level surfaces at fixed cadence. This level is consistent with descriptions of the limited and unlimited household ambulator.

   Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. This level is consistent with descriptions of the limited community ambulator.

   Level 3: Has the ability or potential for ambulation with variable cadence. This level is consistent with descriptions of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

   Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. This level is consistent with the prosthetic demands of the child, active adult, or athlete.

   Note: Consideration is given to bilateral amputees who often cannot be strictly bound by the Classification levels.

   Note: The use of a microprocessor-controlled prosthetic over a standard prosthetic for home use (for example, to climb stairs at home) or for the limited community ambulator (for example, to climb stairs at work) is considered not medically necessary.

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Note: Health plan language regarding prosthetic benefits, special features, and standard models is applicable.

B. Lower limb prostheses (foot, ankle, above/below knee)-must meet criteria from A. above and:

A lower limb-mechanical (non-powered, non-microprocessor): Single axis, fluid swing and stance phase control lower limb addition (HCPCS code L5828) is considered medically necessary when the individual is a functional level 3 or greater as defined above.

A Lower limb-microprocessor-controlled prosthetic device: Any of the following microprocessor-controlled prosthetics, including additions/components that are required for the effective use of the device (and consistent with the user’s function level), are considered medically necessary when the individual is a function level 3 or greater and ANY of the following:

1. ankle-foot prosthetic (HCPCS code L5973) for a transtibial amputee (i.e., below-the-knee)

2. knee prosthetic (HCPCS codes L5856, L5857, L5858)
   a. for a knee disarticulation amputee or a transfemoral amputee (i.e., above-the-knee); AND b. the member has a need for daily long-distance ambulation at variable rates (greater than 400 yards); AND c. has a need for regular ambulation on uneven terrain or for regular use on stairs; AND d. the member has adequate cardiovascular, neuromuscular, and pulmonary reserve needed for ambulating at a faster than baseline rate; AND e. the member demonstrates the ability to ambulate at a faster than baseline rate using a standard prosthetic with a swing and stance control knee; AND f. the member has the cognitive ability to master gait sequencing and care requirements of the higher level of technology; AND g. the member’s function level is a 3 or 4 as defined above.

3. a combination prosthetic/system (e.g., Linx), when a microprocessor- controlled prosthetic knee alone is inadequate to meet the functional needs of the individual (e.g., continued knee/foot instability due to environmental/anatomical barriers).

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4. A microprocessor-controlled prosthetic is considered not medically necessary for any other indication.

   A microprocessor controlled lower limb prosthesis with stance –phase or swing and stance phase microprocessors, utilizing complex sensory systems with additional environmental input (e.g., gyroscope and accelerometer, e.g., Genium™) is considered medically necessary for an above-the-knee amputee and knee disarticulation amputees when all the following criteria are met:

5. All the criteria in section A. (above) area met.

6. The member must have undergone extensive evaluation by a prosthetist and is felt to be of a functional level of at least K3, for a microprocessor knee.

7. Documentation of specific activities / difficulties with current prosthetic that can be addressed with the new prosthetic.

   A Lower limb-powered microprocessor-controlled prosthetic device: an endoskeletal knee-shin system (addition to a lower limb device) with powered and programmable flexion/extension assist control, including any type of motor(s) (HCPCS code L5859) (e.g., Ossur Power Knee) is considered medically necessary when ALL of the following criteria have been met:

8. The individual has a swing and stance phase-type microprocessor controlled (electronic) knee (HCPCS code L5856).
9. the individual is functional level 3 (K3) only.

10. the individual has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3 level function with the use of a microprocessor-controlled knee alone.

    *Note: Coverage of this device is limited to individuals who are Functional Level 3: the device is not intended for high impact activity, sports, excessive loading, or heavy-duty use.

    The following powered prosthetic devices are each considered not medically necessary: microprocessor-controlled ankle foot prosthetic with power assist (e.g., PowerFoot BiOM, iWalk, Proprio Foot, empower Ankle) [HCPCS codes L5973, L5969]); a powered lower limb prosthetic for any other indication.

    AND for microprocessor controlled prosthetic device, ALL the following criteria must be met:

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I. The individual has expressed a willingness to ambulate, and the individual’s current activities daily exceed the capabilities of a standard lower limb prosthetic device.

II. The patient has used a standard lower limb prosthetic device for independent daily activities for a minimum of three (3) months.

III. Medical, physical therapy (rehabilitation) and prosthetist records indicate all the following:

a. That the use of the device will enable the individual to reach a minimum of functional level 3 within three months of obtaining the device. The records must document the individual’s current functional level, the expected functional level, and why the expected functional level cannot be achieved with the current device / prosthesis.

b. That there is no significant cardiovascular, musculoskeletal, pulmonary, or neuromuscular condition that would prohibit maximal use of the device (for example, a cardiac, vascular, orthopedic, pulmonary, or muscular condition that would prevent the individual from achieving a fast-walking pace),

c. Gait analysis documents that the individual can ambulate at a rate faster than what can currently be achieved with a standard prosthesis despite appropriate adjustments to the current prosthesis.

d. Appropriate patient weight and height for the device chosen.

C. Upper Limb Prostheses (finger, hand, wrist, above/below elbow, shoulder)- must meet criteria for A. above and:

An Upper Limb-Myoelectric Prosthetic Device is considered medically necessary for an individual with an amputation or congenital absence of a portion of an arm (e.g., hand, forearm, elbow) when ALL of the following are met:

1. Standard prosthesis (body-powered) is not sufficient to provide functionality for performance of activities of daily living or individual cannot use standard prosthesis.

2. Individual is 2 years old or greater.

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3. Individual has unilateral trans-radial or trans-humeral deficiency and the proximal arm musculature remaining contains the minimum microvolt threshold to operate a myoelectric prosthesis.

4. Individual has the cognitive ability to operate a myoelectric prosthesis and participate in the prosthetic training process.

5. Individual is able to tolerate the weight of the prosthesis.

6. Individual does not have an underlying neuromuscular disease.

   D. Repair and replacement: Replacement of a prosthesis is limited by the health plan to no sooner than every three years after purchase. The decision to repair a prosthetic rather than replace parts is made at the discretion of WPS. Replacement or repair of a prosthesis or a prosthetic part is considered medically necessary when documentation indicates either:

7. There is a change in the physiological condition or functional level of the member, which justifies a new prosthesis or replacement parts. Criteria for the prosthesis must still be met.

   OR

8. There is a change in the condition of the device, or in a part of the device, and both of the following:

   a. The condition of the device (or the part of the device) requires repairs, and the cost of such repairs would be more than the cost of a replacement device or of the part being replaced.

   b. The component or prosthesis in need of replacement is not covered under warranty and need for replacement is not due to improper use. The prosthetist should provide warranty information with the request.

   The reason for replacement for any prosthesis must be clearly documented by the treating practitioner (loss, irreparable damage, or change in member’s condition that cannot be accommodated by modification of the existing prosthesis). Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the excess repairs above the replacement cost.

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The prosthetic device is created from many different components that must be specified in the prescription and prior authorization request. These include microprocessor motors, external battery packs, and all the parts that will be used. The basic parts, depending upon the level of the amputation, include:

• A socket (connection between the residual limb and prosthesis)
• A suspension mechanism (how the socket is attached to the prosthesis)
• A joint (e.g., knee joint which provides support during stance, smooth control during swing phase and unrestricted motion for sitting and kneeling)
• A pylon (a tube or shell that attaches the socket to the terminal device) that is either exoskeleton or endoskeleton.
• A terminal device (e.g., foot or hand)

Note: Up to two test (diagnostic) sockets may be required for accurate fitting of an individual prosthesis. In addition, up to two socket inserts may be required per individual prosthesis at the same time.

Note: Requests for additional test sockets and/or socket inserts require documentation supporting medical necessity such as documentation of functional and/or physiological need, including but not limited to, changes in the residual limb, functional need changes, or irreparable damage or wear/tear due to excessive weight or prosthetic demands of very active amputees.

The following are considered medically necessary when used in conjunction with approved prosthetic devices:

1. Supplies and accessories medically necessary for effective functioning of allowed equipment.
2. Repairs or adjustments to medically necessary prosthetic devices that are required due to bone growth or reasonable weight loss or reasonable weight gain and normal wear and tear during normal usage of the device.
3. Replacement of medically necessary prosthetic devices when repairs or adjustments fail and/or are not possible.
4. Two test (diagnostic) sockets for an individual prosthetic. Additional documentation of medical necessity is required for more than 2 test sockets.
   Test sockets are considered to include all diagnostic procedures.
5. Prosthetic sheaths/socks, including a gel cushion layer (prosthetic gel stockings; 12 in 12 months) are considered medically necessary.
6. No more than 2 socket inserts per individual prosthesis are considered medically necessary.
7. No more than two replacement liners per prosthesis in 12 months are considered medically necessary.

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Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review health plan exclusions and prior authorization or benefit requirements.

B. If requested / used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested / used for a condition or diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary.

D. Microprocessor controlled lower limb prosthesis are considered not medically necessary (not the most cost-effective prosthetic) if the patient’s functional needs could be met with a standard non-electronic prosthetic, or for knee microprocessors and functional levels less than K3.

E. Microprocessor controlled and power lower limb prosthetics and accessories designed for fitness and specialty sports participation and used for activities other than normal daily living (e.g., Ottobock above the knee X-3 waterproof prosthetic, Moto Knee, Sprinte foot) are considered not medically necessary (not the most cost-effective prosthetic) and may also be an exclusion of the member’s certificate.

F. Microprocessor controlled ankle foot prosthetic (e.g., Proprio Foot®) is considered experimental, investigational, and unproven to affect health outcomes.

G. Myoelectric Lower Limb Prosthetic devices are considered experimental, investigational, and unproven to affect health outcomes.

H. Implantable Myoelectric sensors for upper limbs and hands are considered experimental, investigational, and unproven to affect health outcomes.

I. Electric and body-powered partial fingers are considered experimental, investigational, and unproven to affect health outcomes.

J. ReWalk Personal System or other lower body exoskeleton suits for home use in spinal cord injury are considered experimental, investigational, and unproven to affect health outcomes.

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K. Powered Lower Limb Prostheses (e.g., Power Knee, Ossur) when criteria are not met above, are considered experimental, investigational, and unproven to affect health outcomes.

L. Microprocessor-controlled leg prostheses (e.g., Ottobock C-Leg, Ottobock Genium Bionic Prosthetic System, Intelligent Prosthesis, and Ossur Rheo Knee) for gait management in spinal cord injury is considered experimental, investigational, and unproven to affect health outcomes.

M. If more than one prosthetic limb meets a patient’s prosthetic rehabilitation needs, the costlier prosthetic will be considered not medically necessary.

N. Genium3x lower limb prosthetic which utilizes multimodal proprioceptive inputs and can monitor 500 knee motion possibilities, is considered a device with special features/ additional features and/or not the standard model. These devices have additional features (e.g., specific programming) and have not been demonstrated to be superior to a standard device and are not considered the lowest-cost alternative.

O. Kenevo prosthetic knee with built in microprocessors designed for K-2 walkers is considered experimental, investigational, and unproven to affect health outcomes.

P. Vacuum–assisted Socket System is considered experimental, investigational, and unproven to affect health outcomes.

Q. If not specified by the health plan, replacement of a prosthesis within less than 3 years from purchase by this health plan is considered not medically necessary unless all conditions in the Indications of Coverage are met.

R. If repair of a prosthetic limb, or its parts, is less expensive than replacement of the prosthetic, then replacement is considered not medically necessary.

S. Upper-limb prosthetic components with both sensor and myoelectric control (e.g., The LUKE [Life Under Kinetic Evolution] Arm [DEKA Arm] for upper extremity amputation is considered experimental, investigational, and unproven.

T. JACO assistive robotic arm (wheelchair mounted assistive device) are not considered medically necessary as they are considered personal convenience items.

U. C-Brace Leg orthosis for the management of lower extremity paralysis is considered experimental, investigational, or unproven.

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V. 3D Printing of anatomic structures for preoperative planning and other applications is considered experimental, investigational, and unproven.

W. Osseointegrated Prostheses/Osseoanchored Prostheses are considered experimental, investigational, and unproven to affect health outcomes.

X. MyoPro® Orthosis for upper extremity paralysis/paresis after stroke or with a history of cerebral palsy is considered experimental, investigational, and unproven to affect health outcomes.

Y. Robotic rehabilitation / robot-mediated therapy (RMT) of upper extremities in individuals with degenerative neurological conditions is considered experimental, investigational, and unproven to affect health outcomes.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis and must include all of the following elements: A. Member’s name or guideline number B. Order date
C. General description of the item D. The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/ model number E. For equipment-in addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an up-graded code (List each separately). F. For Supplies-in addition to the description of the base item, the DME order/prescription may include all concurrently ordered supplies that are separately billed (List each separately).
G. Quantity to be dispensed, if applicable H. Treating practitioner name or NPI I. Treating practitioner’s signature.
*Treating practitioner is defined as a physician (MD or DO), physician assistant, nurse practitioner, or clinical nurse specialist.
• Proof of Delivery/Direct delivery is required for custom fit and custom fabricated items (date of delivery = date of service): Member’s name; delivery address; description of item(s) being delivered; quantity delivered; date delivered; member’s (or designee) signature.
• Face-to-Face and Written Order Prior to Delivery which should contain authorization, continued need/use, medical records from treating practitioner.

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• Medical record information (including continued need/use if applicable) and medical necessity for prosthetic components and additions, gait analysis report, PAVET score (when appropriate). • Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Durable Medical Equipment DME is only considered “durable” if it is prescribed by a qualified healthcare provider for a medical reason and is not typically useful to someone without a health condition. The equipment is primarily intended for use in the member’s home.

DME including upper and lower limb prostheses are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 10/17/14, 01/01/16, 01/01/17, 01/01/18, 01/01/19, 01/01/20, 12/01/20, 12/01/21, 09/01/22, 09/01/23, 01/01/26 Medical Guideline Committee Approval 09/12/14, 09/11/15, 09/16/16, 09/15/17, 09/21/18, 08/30/19, 07/31/20, 08/26/21, 08/25/22, 08/31/23, 06/26/25 Reviewed

09/12/14, 09/11/15, 09/16/16, 09/15/17, 09/21/18,08/30/19, 07/31/20, 08/26/21, 08/25/22, 08/31/23, RETIRED 7/25/24, 06/26/25 Developed 10/17/14, Renewed as Upper and Lower Extremity Prostheses 6/26/25

 Note: For review/revision history prior to 2014 see previous Medical Guideline

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Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description E0738 UPPER EXTREMITY REHABILITATION SYSTEM PROVIDING ACTIVE ASSISTANCE TO FACILITATE MUSCLE RE-EDUCATION, INCLUDE MICROPROCESSOR, ALL COMPONENTS AND ACCESSORIES
E0739 REHAB SYSTEM WITH INTERACTIVE INTERFACE PROVIDING ACTIVE ASSISTANCE IN REHABILITATION THERAPY, INCLUDES ALL COMPONENTS AND ACCESSORIES, MOTORS, MICROPROCESSORS, SENSORS
L5000 PARTIAL FOOT; SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER L5010 PARTIAL FOOT; MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER L5020 PARTIAL FOOT; MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT L5060 ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT L5150 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT

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L5160 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (‘STUBBIES’), WITH FOOT BLOCKS, NO ANKLE JOINTS, EACH L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT (‘STUBBIES’), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5301 BELOW KNEE, MOLDED SOCKET, SHIN, EACH FOOT, ENDOSKELETAL SYSTEM L5312 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, SINGLE AXIS KNEE, PYLON, SACH FOOT, ENDOSKELETAL SYSTEM L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE L5400 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEE (BK) L5410 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND ASUSPENSION, BELOW KNEE (BK), EACH ADDITIONAL CAST CHANGE AND REALIGNMENT L5420 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE ABOVE KNEE (AK) OR KNEE DISARTICULATION L5430 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, ABOVE KNEE (AK) OR KNEE DISARTICULATION, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT

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L5450 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF NONWEIGHT BEARING RIGID DRESSING, BELOW KNEE (BK) L5560 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF NONWEIGHT BEARING RIGID DRESSING, ABOVE KNEE (AK) L5500 INITIAL, BLEOW KNEE (BK) PTB TYPE SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED L5505 INITIAL, ABOVE KNEE (AK), KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED L5510 PREPARATORY, BELOW KNEE (BK) PTB TYPE SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL L5520 PREPARATORY, BELOW KNEE (BK) PTB TYPE SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED L5530 PREPARATORY, BELWO KNEE (BK) PTB TYPE SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL L5535 PREPARATORY, BELOW KNEE (BK) PTB TYPE SOCKET, NONALIGABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED, ADJUSTABLE ONE-END SOCKET L5540 PREPARATORY, BELOW KNEE (BK) PTB TYPE SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL L5560 PREPARATORY, ABOVE KNEE (AK)-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL L5570 PREPARTORY, ABOVE KNEE (AK)-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED L5580 PREPARATORY, ABOVE KNEE (AK)-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL L5585 PREPARATORY, ABOVE KNEE (AK)-KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NONALIGNABLE SYSTEM, PYLON, NO

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COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN-END SOCKET L5590 PREPARATORY, ABOVE KNEE (AK)-KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NONALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL L5595 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL L5600 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL L5610 ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE (AK), HYDRACADENCE SYSTEM L5611 ADDITIONL TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE (AK), KNEE DISARTICULATION, FOUR-BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL L5613 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK), KNEE DISARTICULATION, FOUR-BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL L5614 ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE (AK), KNEE DISARTICULATION, FOUR-BAR LINKAGE, WITH PNEUAMTIC SWING PHASE CONTROL L5615 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 4 BAR LINKAGE OR MULTIAXIAL, FLUID SWING AND STANCE PHASE CONTROL
L5616 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTM, ABOVE KNEE (AK), UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL L5617 ADDITION TO LOWER EXXTREMITY, QUICK CHANGE SELF- ALIGNING UNIT, ABOVE KNEE (AK) OR BELOW KNEE (BK), EACH L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE (BK)

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L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE (AK) L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), ACRYLIC SOCKET L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKET L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK) OR KNEE DISARTICULATION, ACRYLIC SOCKET L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE, PTD BRIM DESIGN SOCKET L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKET L5636 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), MEDIAL OPENING SOCKET L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), TOTAL CONTACT L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), LEATHER SOCKET L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), WOOD SOCKET

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L5640 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET L5642 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), LEATHER SOCKET L5643 ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), WOOD SOCKET L5645 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), FLEXIBLE INNER SOCKET, EXTERNAL FRAME L5646 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK0, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK) SUCTION SOCKET L5648 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE (AK) OR KNEE DISARTICULATION SOCKET L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), FLEXIBLE INNER SOCKET, EXTERNAL FRAME

L5652 ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE (AK) OR KNEE DISARTICULATION SOCKET L5653 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET

Page 18 of 32

L5654 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5655 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (BK) (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5656 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5658 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (AK) (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5661 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTIDUROMETER SYMES L5665 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTIDUROMETER, BELOW KNEE (BK) L5666 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), CUFF SUSPENSION L5668 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), MOLDED DISTAL CUSHION L5670 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), MOLDED SUPRACONDYLAR SUSPENSION (PTS OR SIMILAR) L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK)/ABOVE KNEE (AK) SUSPENSION LCOKING MECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERT L5672 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), REMOVABLE MEDIAL BRIM SUSPENSION L5673 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK)/ABOVE KNEE (AK), CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM L5676 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE (BK), KNEE JOINTS, SINGLE AXIS, PAIR

Page 19 of 32

L5677 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE (BK), KNEE JOINTS, POLYCENTRIC, PAIR L5678 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE (BK), JOINT COVERS, PAIR L5679 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK)/ABOVE KNEE (AK), CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM L5680 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), THIGH LACER, NONMOLDED L5681 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK)/ABOVE KNEE (AK), CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679) L5682 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), THIGH LACER, GLUTEAL/ISCHIAL,MOLDED L5683 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK)/ABOVE KNEE (AK), CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679) L5684 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), FORK STRAP

L5685 ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE (BK), SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE, ANY MATERIAL, EACH L5686 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), BACK CHECK (EXTENSION CONTROL) L5688 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), WAIST BELT, WEBBING

Page 20 of 32

L5690 ADDITION TO LOWER EXTREMITY, BELOW KNEE (BK), WAIST BELT, PADDED AND LINED L5692 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), PELVIC CONTROL BELT, LIGHT L5694 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), PELVIC CONTROL BELT, PADDED AND LINES L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK), PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE OR EQUAL, EACH L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK) OR KNEE DISARTICULATION, PELVIC JOINT L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK) OR KNEE DISARTICULATION, PELVIC BAND L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEE (AK) OR KNEE DISARTICULATION, SILESIAN BANDAGE L5699 ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESS L5700 REPLACEMENT, SOCKET, BELOW KNEE (BK), MOLDED TO PATIENT MODEL L5701 REPLACEMENT, SOCKET, ABOVE KNEE (AK)/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL L5702 REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL

L5703 ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY L5704 CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE (BK)

Page 21 of 32

L5705 CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE (AK) L5706 CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION L5707 CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION L5710 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK L5711 ADDITION, EXCOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL L5712 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) L5714 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING PHASE CONTROL L5716 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK L5718 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND STANCE PHASE CONTROL L5720 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES L5722 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL
L5724 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL L5726 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL

Page 22 of 32

L5728 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL L5780 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL L5781 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM (VACUUM-ASSISTED SOCKET SYSTEM [VASS]) L5782 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM, HEAVY-DUTY L5783 ADDITION TO LOWER EXTREMITY, USER ADJUSTABLE, MECHANICAL, RESIDUAL LIMB VOLUME MANAGEMENT SYSTEMS
L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE (BK), ULTRA- LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE (AK0, ULTRA- LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5795 ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA- LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL
L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) L5814 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK

Page 23 of 32

L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND STANCE PHASE CONTROL L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL
L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL
L5826 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME L5827 ENDOSCKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, ELECTROMECHANICAL SWING AND STANCE PHASE CONTROL, WITH OR WITHOUT SHOCK ABSORBTION AND STANCE EXTENSION DAMPING L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/SWING PHASE CONTROL L5840 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, FOUR-BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL L5841 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, PNEUMATIC SWING, AND STANCE PHASE CONTROL
L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE L5848 ADDITION TO ENDOSKELETAL, KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE WITH OR WITHOUT ADJUSTABILITY L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK) OR HIP DISARTICULATION, KNEE EXTENSION ASSIST L5855 ADDITION, ENDOSKELETAL SYSTEM, HIP DIARTICULATION, MECHANICAL HIP EXTENSION ASSIST

Page 24 of 32

L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE L5859 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S) L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE (BK),
ALIGNABLE SYSTEM L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK) OR HIP DISARTICULATION, ALIGNABLE SYSTEM L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK), KNEE DISARTICULATION OR HIP DISARTICULATION, MANUAL LOCK
L5926 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL, KNEE DISARTICULATION, ABOVE KNEE, HIP DISARTICULATION, POSITIONAL ROTATION UNIT, ANY TYPE L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE (BK), ULTRA- LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK), ULTRA- LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

Page 25 of 32

L5961 ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL, ROTATION CONTROL, WITH OR WITHOUT FLEXION AND/OR EXTENSION CONTROL
L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE (BK), FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE (AK), FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER FURFACE COVERING SYSTEM L5968 ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE L5969 ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S) L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL HEEL, SACH FOOT L5971 ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY L5972 ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE HEEL L5973 ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS, ANKLE/FOOT L5975 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE HEEL FOOT L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR EQUAL) L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT

Page 26 of 32

L5979 ALL LOWER EXTREMITY PROSTHESIS, MULTIAXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLON L5986 ALL LOWER EXTREMITY PROSTHESES, MULTIAXIAL ROTATION UNIT (MCP OR EQUAL) L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON L5988 ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE L5990 ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHT L5991 ADDITION TO LOWER EXTREMITY PROSTHESIS, OSSEOINTEGRATED EXTERNAL PROSTHETIC CONNECTOR (OPRA IMPLANT SYSTEM) L5999 LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED

Page 27 of 32

L6026 TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF- SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE, EXCLUDES TERMINAL DEVICE(S) L6028 PARTIAL HAND INCLUDING FINGERS, FLEXIBLE OR NON-FLEXIBLE INTERFACE, ENDOSKELETAL SYSTEM, MOLDED TO PATIENT MODEL, FOR USE WITHOUT EXTERNAL POWER, NOT INCLUDING INSERTS DESCRIBED BY L6692 L6029 UPPER EXTREMITY ADDITION, TEST SOCKET/INTERFACE, PARTIAL HAND INCLUDING FINGERS L6030 UPPER EXTREMITY ADDITION, EXTERNAL FRAME, PARTIAL HAND INCLUDING FINGERS L6031 REPLACEMENT SOCKET/INTERFACE, PARTIAL HAND INCLUDING FINGERS, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER L6032 ADDITION TO UPPER EXTREMITY PROSTHESIS, PARTIAL HAND INCLUDING FINGERS, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER, OR EQUAL) L6033 ADDITION TO UPPER EXTREMITY PROSTHESIS, PARTIAL HAND INCLUDING FINGERS, ACRYLIC MATERIAL L6037 IMMEDIATE POSTSURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, PARTIAL HAND INCLUDING FINGERS L6611 ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY TYPE L6621 UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE L6629 UPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATAION COLLAR WITH COUPLING PIECE, OTTO BOCK OR EQUAL L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH

Page 28 of 32

L6677 UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TERMINAL DEVICE AND ELBOW L6680 UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULATION OR BELOW ELBOW L6682 UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULATION OR ABOVE ELBOW L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET L6687 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST DISARTICULATION L6688 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW DISARTICULATION L6694 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM L6695 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM L6696 ADDITION TO UPPER EXTREMITY PROSTHEIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695) L6697 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICTED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL USE CODE L6694 OR L6695)

Page 29 of 32

L6698 ADDITION TO UPPER EXTREMITY PROSTHESIS, LOCK MECHANISM, EXCLUDES SOCKET INSERT L6700 UPPER EXTREMITY ADDITION, EXTERNAL POWERED FEATURE, MYOELECTRIC CONTROL MODULE, ADDITIONAL EMG INPUTS, PATTERN-RECOGNITION DECODING INTENT MOVEMENT L6715 TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT L6880 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, ANY GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S) L6881 AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE L6882 MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE L6883 REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER L6884 REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER L6890 ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L6925 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6935 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6940 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

Page 30 of 32

L6945 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6965 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6975 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT L7008 ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT L7045 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC L7180 ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE L7181 ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL DEVICE L7190 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED L7191 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED L7259 ELECTRONIC WRIST ROTATOR, ANY TYPE L7360 SIX VOLT BATTERY, EACH

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L7364 TWELVE VOLT BATTERY, EACH L7366 BATTERY CHARGER, TWELVE VOLT, EACH L7367 LITHIUM-ION BATTERY, RECHARGABLE, REPLACEMENT L7368 LITHIUM-ION BATTERY CHARGER, REPLACEMETN ONLY L7400 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L7401 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L7403 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYLIC MATERIAL L7404 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MATERIAL L7406 ADDITION TO UPPER EXTREMITY, USER ADJUSTABLE, MECHANICAL, RESIDUAL LIMB VOLUME MANAGEMENT SYSTEM L7600 PROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACH L7700 GASTKET OR SEAL, FOR USE WITH PROSTHETIC SOCKET INSERT, ANY TYPE, EACH L8400 PROSTHETIC SHEATH, BELOW KNEE (BK), EACH L8410 PROSTHETIC SHEATH, ABOVE KNEE (AK), EACH L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE (BK), OR ABOVE KNEE (AK), EACH L8420 PROSTHETIC SOCK, MUTLIPLE PLY, BELOW KNEE (BK), EACH L8430 PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE (AK), EACH L8440 PROSTHETIC SHRINKER, BELOW KNEE (BK), EACH L8460 PROSTHETIC SHRINKER, ABOVE KNEE (AK), EACH

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L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH L8470 PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE (BK), EACH L8480 PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE (AK), EACH L8702 POWERED UPPER EXTREMITY RANGE OF MOTION ASSIST DEVICE, ELBOW, WRIST, HAND, FINGER, SINGLE OR DOUBLE UPRIGHT(S), INCLUDES MICROPROCESSOR, SENSORS, ALL COMPONENTS AND ACCESSORIES, CUSTOM FABRICATED