Humana Prosthetics Form

Description

A prosthesis or prosthetic is an artificial device that replaces a missing body part. Examples of prostheses include arms, breasts, ears, feet, hands, legs and maxillofacial (jaw and face).

Lower limb prostheses are designed to replace portions of the lower extremity to improve function. A prosthetic knee performs several functions: it provides support during the stance phase of ambulation, produces smooth control during the swing phase and maintains unrestricted motion for sitting and kneeling. The prosthetic knee may have a single axis with a simple hinge and a single pivot point or it may have a polycentric axis with multiple centers of rotation, which is more similar to the anatomic human knee.

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The prosthetic foot also has several basic functions; provides a stable weight-bearing surface, absorbs shock, replaces lost muscle function and biomechanics of the foot, replicates the anatomic joints of the ankle and foot and restores appearance.

Multiaxial prosthetic feet permit movements in any direction: plantar flexion, dorsiflexion, inversion, eversion and a slight amount of rotation around a vertical axis. Multiaxial feet are appropriate for those who ambulate on uneven terrain, such as community ambulators and active adults or athletes.

The solid ankle cushion heel (SACH) consists of a rigid keel covered by semi-noncompressible foam and a synthetic rubber heel wedge. The cushion heel compresses when weight is applied, allowing the forefoot to approach the floor. The amount of simulated plantar flexion depends on the relative softness of the heel material and weight of the amputee. Because the keel is rigid, the SACH foot does not provide dorsiflexion; this makes its usefulness on uneven surfaces limited.

A residual limb volume management and moisture evacuation system (e.g., Vacuum Assisted Socket System [VASS], Limb Bionic) is a specialized device used with artificial limbs in an attempt to manage residual limb volume fluctuation. The system consists of a liner, suspension sleeve and air evacuation pump. The device creates an elevated vacuum between the liner and the socket wall. The elevated vacuum attempts to promote natural fluid exchange to regulate volume fluctuation in the residual limb, reduce forces to the residual limb and increase suspension and balance.

Upper limb prostheses are classified into the following categories:

• Body powered utilizes a body harness and cable system to provide functional manipulation. Voluntary movement of the shoulder and/or limb stump extends the cable system and transmits force to the device to control hand, forearm and elbow movement.
• Hybrid is a combination of body powered and myoelectric components and may be used for high-level amputations (at or above the elbow). Hybrid systems allow control of 2 joints at once.
• Myoelectric utilizes muscle activity from the residual limb for control of joint movement.

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Electromyographic signals from the limb stump are detected by surface electrodes, amplified and then processed by a controller to drive battery powered motors that move the hand, wrist and elbow. These devices operate on rechargeable batteries and require no external cables or harnesses.

• Passive is the lightest and serves mostly a cosmetic purpose as it does not restore any function and must be repositioned manually, typically by moving it with the opposite arm.

A multiarticulating, myoelectric hand prosthetic (e.g., bebionic, iLimb, Michelangelo, Vincent) functions by individually powering all 5 digits to grasp by conforming to the objects shape and fluctuating the grip strength. Devices vary in function and options including, but not limited to, the ability to be controlled by a mobile device app, conductive tips for mobile device use, multiple wrist options and skin colored silicone glove covers (e.g., Livingskin). The prosthetic is described as anthropomorphic (human like) in its appearance and shape.

A partial hand myoelectric prosthetic (e.g., ProDigits) replaces the function of one or more missing fingers because of a partial hand amputation. It is intended for use for an amputation at a transmetacarpal (part of the hand but not the wrist itself) level or higher. (Refer to Coverage Limitations section)

An adjustable click prosthesis (e.g., BOA, RevoFit) is a self-adjustable prosthetic socket. The click reel consists of an adjustable dial, strong lightweight laces and lace guides. The dial incorporates a gearing mechanism that advances the lace and moveable portions. Turning the click reel engages the lacing system that adjusts predetermined areas of the socket custom to each individual’s needs. It purportedly allows for control of compression and expansion to manage residual limb volume fluctuation and ease of donning and doffing. (Refer to Coverage Limitations section)

An enhanced-dexterity prosthetic arm (e.g., Life Under Kinetic Evolution [LUKE] Arm) is an upper limb prosthesis that was developed to restore function in those individuals who have lost all or part of their upper limb. It is primarily controlled by a micro-electromechanical system that is operated through an inertial measurement unit (IMU), which is located in a sensor that is attached to or embedded in the individual’s shoe. By lifting the foot in various directions, it purportedly commands the motion of the prosthesis. (Refer to Coverage Limitations section)

An osseointegrated prosthesis for the rehabilitation of amputees (OPRA), is an osseointegration device, also referred to as osseoanchored device (bone anchored) intended for skeletally mature individuals (bone growth is complete) who have transfemoral amputation due to trauma or cancer. (Refer to Coverage Limitations section)

For information regarding iris prosthesis, please refer to Code Compendium (Ophthalmology) Medical Coverage Policy.

For information regarding voice prostheses/speech generating devices, please refer to Speech Generating Devices, Voice Prostheses Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for medically necessary prosthesis devices and supplies to restore the previous level of function in order to perform normal activities of daily living (ADL).

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

In addition, the following specific criteria must be met:

Breast

• Humana members may be eligible under the Plan for a basic external breast and/or nipple prosthesis (L8020-L8032) with replacement every 2 years for ordinary wear and tear.
• Humana members may be eligible under the Plan for a maximum of 6 post mastectomy bras (L8000-L8015) per rolling 12-month period following a medically necessary mastectomy.
• A rolling 12 month period is 12 months after an event, regardless of what month the initial event took place.

Eye

• Humana members may be eligible under the Plan for an eye prosthesis (V2623, V2629) due to absence of an eye from a congenital defect, disease, injury or surgical removal.
• Humana members may be eligible under the Plan for one enlargement or reduction (V2625, V2626) of an eye prosthesis.
• Humana members may be eligible under the Plan for polishing and resurfacing (V2624) of a prosthetic eye on a twice-yearly basis.

Facial (including ears)

• Humana members may be eligible under the Plan for a facial prosthesis (21077, 21086-21088, L8040-L8048) for loss or absence of facial tissue due to a congenital defect, disease, injury or surgery.
• For information regarding coverage determination/limitations for the EarWell device, which is not considered to be a prosthetic, please refer to Cosmetic and Reconstructive Surgery Medical Coverage Policy.

LOWER LIMB

Humana members may be eligible under the Plan for a lower limb prosthesis when ALL of the following criteria are met:

1. Prosthesis is needed for ambulation; AND
2. Individual is expected to reach or maintain a defined functional state; AND
3. Medical records document the individual’s current functional capabilities and expected rehabilitation potential is based on functional levels

Humana members may be eligible under the Plan for a basic prosthetic for a functional level of 1. A basic lower limb prosthetic generally includes a SACH foot and a single axis, constant friction knee.

The following anatomy specific criteria apply:

Ankle

• Humana members may be eligible under the Plan for an axial rotation unit (K1022, L5982-L5986) for a functional level of 2 or above.

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Ankle

• Humana members may be eligible under the Plan for an endoskeletal ankle/foot or ankle system, power assist (L5969) for a functional level of 3 or above.

Feet

• Humana members may be eligible under the Plan for an external keel SACH foot (L5970) or single axis ankle/foot (L5974) for a functional level of 1 or above.
• Humana members may be eligible under the Plan for a flexible-keel foot (L5972) or multi-axial ankle/foot (L5978) for a functional level of 2 or above.
• Humana members may be eligible under the Plan for an energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flexwalk system or equal (L5981) or shank foot system with vertical loading pylon (L5987) for a functional level of 3 or above.

Hip

• Humana members may be eligible under the Plan for a pneumatic or hydraulic polycentric hip joint (L5961) for a functional level of 3 or above.

Knee

• Humana members may be eligible under the Plan for a fluid, pneumatic or electronic knee (K1014, L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856-L5858) for a functional level of 3 or above.

Humana members may be eligible under the Plan for an endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) (L5859) when the following criteria are met:

• Functional Level of 3 only; AND
• Individual has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone; AND
• Individual has a swing and stance phase type microprocessor controlled (electronic) knee (L5856); AND
• Individual is able to operate the device (daily charging, understand and respond to error alerts and alarms indicating problems with the function of the unit)

*The device is not intended for high impact activity, sports, excessive loading, or heavy duty use

• Humana members may be eligible under the Plan for other knee systems (L5611, L5616, L5710-L5718, L5810-L5812, L5816, L5818) for a functional level of 1 or above.
• Humana members may be eligible under the Plan for a high activity knee control frame (L5930) for a functional level of 4.

Humana members may be eligible under the Plan for residual limb volume management and moisture evacuation system (e.g., Vacuum Assisted Socket System [VASS]) (L5781, L5782) when the following criteria are met:

• Absence of contraindications; AND one of the following:
• Diabetes or occlusive arterial disease; OR
• Excessive residual limb hyperemia from prior socket use; OR
• Excessive skin hyperhidrosis from prior socket use that has not responded to treatment (e.g., over-the-counter [OTC] and prescription antiperspirant, sheath or sock under liner); OR
• Failure of other socket-suspension systems (e.g., mechanical, passive suction) to provide secure fit that cannot be resolved by adjustments; OR
• Multiple falls in transtibial amputees; OR
• Non-healing skin ulcerations on stump; OR

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

Page: 8 of 40

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Volume fluctuations of limb up to 2 cm in circumference

Accessories

Humana members may be eligible under the Plan for stump stockings and harnesses (including replacements) when they are essential to the effective use of the artificial limb.

Humana members may be eligible under the Plan for prosthetic sheaths/socks, including a gel cushion layer.

Partial Foot Prosthesis

Humana members may be eligible under the Plan for a partial foot prosthesis (L5000-L5020) due to absence of phalanges and/or metatarsals from a congenital defect, disease, injury or surgical removal.

Prosthetic Shoe

Humana members may be eligible under the Plan for a prosthetic shoe (L3250) for a partial foot amputation when the prosthetic shoe is an integral part of a covered lower limb prosthesis.

Note: The criteria for prosthetic shoe are consistent with the Medicare National Coverage Policy, and therefore apply to Medicare members.

Sockets

Humana members may be eligible under the Plan for no more than 2 test (diagnostic) sockets (L5618-L5628) for an individual prosthesis.

Humana members may be eligible under the Plan for socket inserts (L5654-L5665, L5671, L5673, L5679, L5681, L5683) for an individual prosthesis.

UPPER EXTREMITY Body Powered

Humana members may be eligible under the Plan for a body powered upper extremity prosthesis when this type of prosthesis meets the functional needs to perform normal ADLs.

Myoelectric including Hybrid

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for a myoelectric upper extremity prosthesis and hand prosthesis when ALL of the following criteria are met:

• Absence of a comorbidity that could interfere with maintaining function of the prosthesis (e.g., neuromuscular disease); AND
• Amputation or missing limb at the wrist or above (e.g., forearm or elbow); AND
• Remaining musculature of the arm contains the minimum microvolt threshold to allow operation of the prosthesis; AND
• Standard body powered prosthesis is insufficient to meet the functional needs to perform normal ADLs; AND
• Sufficient cognitive and neurological function to operate the prosthesis effectively

Testicular

Humana members may be eligible under the Plan for a testicular prosthesis (54660) for congenitally absent testes or testes that are surgically removed due to disease (e.g., cancer) or injury.

Humana members may be eligible under the Plan for a testicular prosthesis (54660) when criteria are met for gender affirming surgery.

For information regarding coverage determination/limitations, please refer to Gender Affirmation Surgery Medical Coverage Policy.

Repair (L7510, L7520) and Replacement (L8049)

Humana members may be eligible under the Plan for repair of a prosthesis, if not covered by the manufacturer, when required due to a change in the individual’s physical condition causing the device to become nonfunctional, OR normal wear and tear renders the device nonfunctional and the repair will make the device usable.

Humana members may be eligible under the Plan for replacement of a prosthesis, if not covered by the manufacturer AND replacement cost is less than the repair cost, when the following criteria are met:

• Change in the individual’s physical condition causing the device to become nonfunctional and nonrepairable; OR
• Normal wear and tear renders the device nonfunctional and nonrepairable

Humana members may be eligible under the Plan for replacement of sockets or socket inserts if there is documentation of functional and/or physiological need (eg, changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to individual’s weight or prosthetic demands of very active amputees).

Coverage Limitations

Humana members may NOT be eligible under the Plan for a prosthesis for any indications other than those listed above including, but may not be limited to, the following:

• Custom fabricated breast prosthesis (L8035, L8039); OR
• Custom fabricated nipple prosthesis (L8033); OR
• Duplication or upgrade of a functional prosthesis; OR
• Gloves for an upper extremity prosthesis (L6890, L6895); OR
• Limit of 2 test (diagnostic) sockets (L5618-L5628) per individual prosthesis at the same time; OR
• Lower limb prosthesis for a functional level of 0; OR
• Microprocessor controlled ankle foot system (L5973); OR
• Prosthetic donning sleeve (L7600) (convenience item); OR
• Prosthetics used for activities other than normal daily living, including, but may not be limited to, those utilized for sporting activities such as skiing; OR

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Repair (L7510, L7520) or replacement (L8049) of a prosthesis for appearance, comfort, convenience or individual abuse, misuse or neglect; OR
• Repair (L7510, L7520) or replacement (L8049) of parts of a duplicate prosthesis; OR
• Test sockets (L5618-L5628) for an immediate prosthesis (L5400-L5460); OR
• User-adjustable heel height feature (L5990); OR
• Water prosthesis/water submersible (designed to be used for showering, swimming, etc.) (eg, Genium X3) (L5999); OR
• Wigs (A9282) (generally excluded by certificate)

All other indications are considered NOT medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the following prosthetic devices:

• Adjustable click prosthesis (eg, BOA, Revo) (L5999, L7499); OR
• Enhanced dexterity prosthetic arm (Life Under Kinetic Evolution [LUKE] Arm) (L7499); OR
• Myoelectric partial hand prosthesis (eg, ProDigits) (L6026); OR
• Osseointegrated prosthesis for the rehabilitation of amputees (OPRA Implant System) (L5991, L5999, L8699)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Prosthetics Effective Date: 11/2/2023

Revision Date: 11/2/2023

Review Date: 11/2/2023

Policy Number: HUM-0331-035

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for residual limb volume management and moisture evacuation system (eg, Vacuum Assisted Socket System [VASS]) (L5781, L5782) for any of the following contraindications:

• Neuroma preventing individual from being able to bear pressure on the residual limb; OR
• Individual is receiving dialysis; OR
• Individual is unable to operate the system; OR
• Individual is undergoing interim fittings; OR

This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about limb loss and prosthetics may be found from the following websites:

Background

• National Library of Medicine
• United States Department of Veterans Affairs

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.