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L.1.04.401
Prosthetics are artificial substitutes which replace all or part of a body organ, or replace all or part of the function of a permanently inoperative, absent, or malfunctioning body part.
A prosthetic sheath may be used alone, placed directly on an amputated limb, or under a prosthetic sock. These garments wick away moisture and help prevent skin breakdown.
Prosthetic appliances are considered medically necessary when prescribed by a qualified provider to replace absent or nonfunctioning parts of the human body by an artificial substitute, whether surgically implanted or worn as an anatomic supplement. Prosthetic appliances include:
Surgical Prostheses:
Artificial joints necessary for joint repair and reconstructive surgery
Breasts, internal and external (including a surgical brassiere), for post-mastectomy reconstruction
Cardiac pacemakers, atomic or electronic
Intra-ocular lenses (Conventional Lenses only, NOT Presbyopia-Correcting Intraocular Lenses*)
Maxillofacial and intra-ocular lenses* as replacement of either surgically removed or congenitally absent crystalline lenses of the eye
Adjustable continence device for treatment of stress incontinence (N39.3) as a result of a radical prostatectomy or transurethral resection of the prostate (i.e. ProACT device).
Nonsurgical Prostheses:
Artificial eyes
Artificial limbs replacing all or part of absent extremities
Speech aids (does not include computers; hardware or software)
Urinary collection and retention systems (Foley catheters, tubes, bags, etc.) in cases of permanent urinary incontinence.
Seven (7) prosthetic sheaths and seven (7) pair of prosthetic socks are covered per year.
The following are non-covered prosthetic devices:
Dentures replacing teeth or structures directly supporting teeth
(Note: Dentures are covered if natural teeth are removed after radiation therapy. This is a one time coverage.
Hairpieces for male-pattern alopecia
Hearing aids
Implants for cosmetic purposes
Electrical continence aids, either anal or urethral
Penile prostheses
Wigs
*Providers may bill the patient the additional expenses associated with insertion of accommodative lenses if the patient signs a waiver specific to non-coverage of accommodative lenses for the specific date of service the lens is inserted. An example would be crystalens or other accommodative lenses such as the AcySof ReSTOR Apodized Diffractive Optic Posterior Chamber Intraocular Lens to correct presbyopia. In addition, any charges for additional treatments, services, supplies or other associated charges required to insert, adjust or follow-up a presbyopia-correcting intraocular lens (IOL) following removal of a cataract that exceed the physician charges for services and supplies for the insertion and adjustment of a conventional IOL are also not covered.
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
No benefits will be available for fitting or adjustments as this is included in the allowable charge for the prosthetic appliance.
Benefits will be provided for repair or replacement of the prosthetic appliance after a reasonable length of time. This time period will be determined by the company.
Benefits based on the allowable charge for standard equipment will be provided toward any deluxe equipment when selected by the member solely for the member's comfort or convenience.
Benefits for deluxe equipment based on the allowable charge for deluxe equipment will only be provided when documented to be medically necessary.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
11/1997: Approved by Medical Policy Advisory Committee (MPAC)
9/19/2000: Speech aids (does not include computers; hardware or software) added
2/28/2002: Prior Authorization and Managed Care Requirements deleted
3/13/2002: New 2002 codes added, CPT code 54406, 54408, 54410, 54411, 54415, 54416, 54417 added, HCPCS K0542 added
5/2/2002: Type of Service and Place of Service deleted
5/9/2002: Denture coverage "exception" added
12/11/2002: CPT 92330,92335,92393added
3/13/2003: Code Reference section updated, HCPCS K0556, K0558, K0559, L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0474, L0476, L0478, L0480, L0482, L0484, L0486, L0488, L0490, L1652, L1836, L1901, L3651, L3652, L3701, L3762, L3909, L3911, L4386, L5781, L5782, L5848, L5995, L6025, L6638, L6646, L6647, L6648, added, HCPCS range L5000-L7499, L8000-L8670, V2623-V2629 listed separately
7/27/2005: Policy section statement "Penile prostheses in men suffering impotency resulting from disease or injury" changed to "Penile prostheses," Code Reference section updated, non-covered codes table added, CPT code 54406, 54408, 54410, 54411, 54415, 54416, 54417 moved from covered to non-covered codes, CPT code 54400, 54401, 54405, 92590, 92591, 92592, 92593, 92594, 92595 added non-covered codes, CPT code 21076, 21077, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087, 21088, 21089, 92597, 92605, 92607, 92608 added covered codes, ICD-9 procedure code 95.48 added non-covered codes, ICD-9 procedure code 95.34 added covered codes, HCPCS L7900, S0618, S8095, V5008, V5010, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5095, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5266, V5267, V5268, V5269, V5270, V5271, V5272, V5273, V5274, V5275, V5298, V5299 added non-covered codes, HCPCS L8230 moved from covered to non-covered, HCPCS D5911, D5912, D5913, D5914, D5915, D5916, D5919, D5922, D5923, D5924, D5925, D5926, D5927, D5928, D5929, D5931, D5932, D5933, D5934, D5935, D5936, D5937, D5951, D5952, D5953, D5954, D5955, D5958, D5959, D5960, D5982, D5983, D5984, D5985, D5986, D5987, D5988, D5999, L5673, L5679, L5681, L5683, L7367, L7500, L7510, L7520, L8511, L8512, L8513, L8514, L8631, L8699, Q1001, Q1002, Q1003, Q1004, Q1005, V2630, V2631, V2632 added covered codes, HCPCS L5685, L5856, L5857, L6694, L6695, L6696, L6697, L6698, L7181, L8515 with effective date 1/1/2005 added covered codes, HCPCS K0440-K0449, K0542, K0556, K0557, K0558, K0559, L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0474, L0476, L0478, L0480, L0482, L0484, L0486, L0488, L0490, L1652, L1836, L1901, L3651, L3652, L3701, L3762, L3909, L3911, L4386, L5660, L5662, L5663, L5664 deleted covered codes, HCPCS L5674, L5675, L5846, L5847, L5989, L8490 deletion date of 12/31/2004 added
11/16/2005: Code Reference section updated, HCPCS code K0670 added
3/13/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
4/19/2006: Policy reviewed, intraocular lens statement clarified
9/27/2006: Coding updated. ICD9 revisions added to policy
9/28/2006: Code reference section updated. CPT codes 66982, 66983, 666984 and V2788 added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
12/15/2009: Code Section revised with 2010 CPT4 and HCPCS revisions
06/21/2011: Added HCPCS code L7368 to the Covered Codes table.
12/31/2014: Added the following new 2015 HCPCS codes to the Code Reference section: L6026 and L7259. Revised the description of the following HCPCS code: L7367.
08/31/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes A6542 and A6543.
04/26/2016: Policy Guidelines updated to add medically necessary definition. Code Reference section updated to remove deleted HCPCS codes L6025, L7260, and L7261 from the Covered Codes table.
05/31/2016: Policy number L.1.04.401 added.
12/22/2017: Code Reference section updated to add new 2018 HCPCS code L7700. Revised description for CPT code 97761 effective 01/01/2018.
12/20/2018: Code Reference section updated to add new HCPCS codes V5171, V5172, V5181, V5211, V5212, V5213, V5214, V5215, and V5221, effective 01/01/2019.
12/19/2019: Code Reference section updated to add new CPT codes 66987, 66988, and HCPCS code L8033. Revised code descriptions for CPT codes 66982, 66984, and HCPCS code L8032. Removed deleted CPT code 97762. Effective 01/01/2020.
09/23/2020: Code Reference section updated to add new HCPCS code K1007, effective 10/01/2020. Removed deleted HCPCS codes V5170, V5180, V5210, and V5220.
11/04/2020: Code Reference section updated to remove HCPCS code K1007.
03/03/2023: Not Medically Necessary Codes table renamed Non-Covered Codes table. Moved L5703 to the Medically Necessary Codes table.
05/10/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
08/15/2023: Code Reference section updated to remove HCPCS code L5973.
09/27/2023: Code Reference section updated to add new HCPCS code L5991, effective 10/01/2023.
12/21/2023: Code Reference section updated to add new 2024 HCPCS codes A6520, A6521, A6522, A6523, A6524, A6525, A6526, A6527, A6528, A6529, A6552, A6553, A6554, A6555, A6556, A6557, A6558, A6559, A6560, A6561, A6562, A6563, A6564, A6565, A6566, A6567, A6568, A6569, A6570, A6571, A6572, A6573, A6574, A6575, A6576, A6577, A6578, A6579, A6580, A6581, A6582, A6583, A6584, A6585, A6586, A6587, A6588, A6589, A6593, A6594, A6595, A6596, A6597, A6598, A6599, A6600, A6601, A6602, A6603, A6604, A6605, A6606, A6607, A6608, A6609, and A6610. Revised the code descriptions for HCPCS codes A6531, A6532, and A6545, effective 01/01/2024.
03/27/2024: Code Reference section updated to add new HCPCS codes L5783 and L5841, effective 04/01/2024.
06/24/2024: Policy reviewed; no changes.
08/06/2024: Policy section updated regarding surgical prostheses. Sources updated. Code Reference section updated to add CPT codes 53451, 53452, 53453, and 53454 to the Covered Codes table. Removed HCPCS codes L8630, L8631, and L8658 as they are addressed in the Pyrocarbon Metacarpophalangeal and Proximal Interphalangeal Joint Implants medical policy.
10/01/2024: Code Reference section updated to add new HCPCS code E2513.
04/01/2025: Code Reference section updated to add new HCPCS codes A6515, A6516, A6517, A6518, A6519, A6611, L6028, L6029, L6030, L6031, L6032, L6033, and L7406, effective 04/01/2025.
10/01/2025: Code Reference section updated to add new HCPCS codes L5657, L6034, L6038, and L6039.
01/01/2026: Code Reference section updated to add new CPT codes 92628, 92629, 92631, 92632, 92634, 92635, 92636, 92637, 92638, 92639, 92641, and 92642.
Blue Cross & Blue Shield Association policy #1.04.01
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination.
Hayes Medical Technology Directory
Incontinence Control Devices. https://CMS.gov/ . Last accessed July 2024.
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Code Number | Description | ||
CPT-4 | |||
21076, 21077, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087, 21088, 21089 | Impression and custom preparation of maxillofacial prosthesis code range | ||
53451 | Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance | ||
53452 | Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance | ||
53453 | Periurethral transperineal adjustable balloon continence device; removal, each balloon | ||
53454 | Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume | ||
66982 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation | ||
66983 | Intracapsular cataract extraction with insertion of intraocular lens prosthesis | ||
66984 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation | ||
66987 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation | ||
66988 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation | ||
92597 | Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech | ||
92605 | Evaluation for prescription of non-speech-generating augmentative and alternative communication device | ||
92607, 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device code range | ||
97761 | Prosthetic training, upper and/or lower extremity(ies) initial prosthetic(s) encounter, each 15 minutes | ||
HCPCS | |||
A6515 | Gradient compression wrap with adjustable straps, full leg, each, custom | ||
A6516 | Gradient compression wrap with adjustable straps, foot, each, custom | ||
A6517 | Gradient compression wrap with adjustable straps, below knee, each, custom | ||
A6518 | Gradient compression wrap with adjustable straps, arm, each, custom | ||
A6519 | Gradient compression garment, not otherwise specified, for nighttime use, each | ||
A6520 | Gradient compression garment, glove, padded, for nighttime use, each | ||
A6521 | Gradient compression garment, glove, padded, for nighttime use, custom, each | ||
A6522 | Gradient compression garment, arm, padded, for nighttime use, each | ||
A6523 | Gradient compression garment, arm, padded, for nighttime use, custom, each | ||
A6524 | Gradient compression garment, lower leg and foot, padded, for nighttime use, each | ||
A6525 | Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each | ||
A6526 | Gradient compression garment, full leg and foot, padded, for nighttime use, each | ||
A6527 | Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each | ||
A6528 | Gradient compression garment, bra, for nighttime use, each | ||
A6529 | Gradient compression garment, bra, for nighttime use, custom, each | ||
A6530 | Gradient compression stocking, below knee, 18-30 mmhg, each | ||
A6531 | Gradient compression stocking, below knee, 30-40 mmhg, used as a surgical dressing, each | ||
A6532 | Gradient compression stocking, below knee, 40-50 mmhg, used as a surgical dressing, each | ||
A6533 | Gradient compression stocking, thigh length, 18-30 mmhg, each | ||
A6534 | Gradient compression stocking, thigh length, 30-40 mmhg, each | ||
A6535 | Gradient compression stocking, thigh length, 40-50 mmhg, each | ||
A6536 | Gradient compression stocking, full length/chap style, 18-30 mmhg, each | ||
A6537 | Gradient compression stocking, full length/chap style, 30-40 mmhg, each | ||
A6538 | Gradient compression stocking, full length/chap style, 40-50 mmhg, each | ||
A6539 | Gradient compression stocking, waist length, 18-30 mmhg, each | ||
A6540 | Gradient compression stocking, waist length, 30-40 mmhg, each | ||
A6541 | Gradient compression stocking, waist length, 40-50 mmhg, each | ||
A6544 | Gradient compression stocking, garter belt | ||
A6545 | Gradient compression wrap, non-elastic, below knee, 30-50 mmhg, used as a surgical dressing, each | ||
A6549 | Gradient compression stocking, not otherwise specified | ||
A6552 | Gradient compression stocking, below knee, 30-40 mmhg, each | ||
A6553 | Gradient compression stocking, below knee, 30-40 mmhg, custom, each | ||
A6554 | Gradient compression stocking, below knee, 40 mmhg or greater, each | ||
A6555 | Gradient compression stocking, below knee, 40 mmhg or greater, custom, each | ||
A6556 | Gradient compression stocking, thigh length, 18-30 mmhg, custom, each | ||
A6557 | Gradient compression stocking, thigh length, 30-40 mmhg, custom, each | ||
A6558 | Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each | ||
A6559 | Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each | ||
A6560 | Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each | ||
A6561 | Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each | ||
A6562 | Gradient compression stocking, waist length, 18-30 mmhg, custom, each | ||
A6563 | Gradient compression stocking, waist length, 30-40 mmhg, custom, each | ||
A6564 | Gradient compression stocking, waist length, 40 mmhg or greater, custom, each | ||
A6565 | Gradient compression gauntlet, custom, each | ||
A6566 | Gradient compression garment, neck/head, each | ||
A6567 | Gradient compression garment, neck/head, custom, each | ||
A6568 | Gradient compression garment, torso and shoulder, each | ||
A6569 | Gradient compression garment, torso/shoulder, custom, each | ||
A6570 | Gradient compression garment, genital region, each | ||
A6571 | Gradient compression garment, genital region, custom, each | ||
A6572 | Gradient compression garment, toe caps, each | ||
A6573 | Gradient compression garment, toe caps, custom, each | ||
A6574 | Gradient compression arm sleeve and glove combination, custom, each | ||
A6575 | Gradient compression arm sleeve and glove combination, each | ||
A6576 | Gradient compression arm sleeve, custom, medium weight, each | ||
A6577 | Gradient compression arm sleeve, custom, heavy weight, each | ||
A6578 | Gradient compression arm sleeve, each | ||
A6579 | Gradient compression glove, custom, medium weight, each | ||
A6580 | Gradient compression glove, custom, heavy weight, each | ||
A6581 | Gradient compression glove, each | ||
A6582 | Gradient compression gauntlet, each | ||
A6583 | Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each | ||
A6584 | Gradient compression wrap with adjustable straps, not otherwise specified | ||
A6585 | Gradient pressure wrap with adjustable straps, above knee, each | ||
A6586 | Gradient pressure wrap with adjustable straps, full leg, each | ||
A6587 | Gradient pressure wrap with adjustable straps, foot, each | ||
A6588 | Gradient pressure wrap with adjustable straps, arm, each | ||
A6589 | Gradient pressure wrap with adjustable straps, bra, each | ||
A6593 | Accessory for gradient compression garment or wrap with adjustable straps, not-otherwise specified | ||
A6594 | Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each | ||
A6595 | Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each | ||
A6596 | Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each | ||
A6597 | Gradient compression bandage roll, elastic long stretch, linear yard, any width, each | ||
A6598 | Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each | ||
A6599 | Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each | ||
A6600 | Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each | ||
A6601 | Gradient compression bandaging supply, high density foam pad, any size or shape, each | ||
A6602 | Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each | ||
A6603 | Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each | ||
A6604 | Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each | ||
A6605 | Gradient compression bandaging supply, padded foam, per linear yard, any width, each | ||
A6606 | Gradient compression bandaging supply, padded textile, per linear yard, any width, each | ||
A6607 | Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each | ||
A6608 | Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each | ||
A6609 | Gradient compression bandaging supply, not otherwise specified | ||
A6610 | Gradient compression stocking, below knee, 18-30 mmhg, custom, each | ||
A6611 | Gradient compression wrap with adjustable straps, above knee, each, custom | ||
D5911, D5912, D5913, D5914, D5915, D5916, D5919, D5922, D5923, D5924, D5925, D5926, D5927, D5928, D5929, D5931, D5932, D5933, D5934, D5935, D5936, D5937, D5951, D5952, D5953, D5954, D5955, D5958, D5959, D5960, D5982, D5983, D5984, D5985, D5986, D5987, D5988, D5999 | Maxillofacial prosthetics code range | ||
L5000, L5010, L5020 | Partial foot code range | ||
L5050, L5060 | Ankle code range | ||
L5100, L5105 | Below knee code range | ||
L5150, L5160 | Knee disarticulation code range | ||
L5200, L5210, L5220, L5230 | Above knee code range | ||
L5250, L5270 | Hip disarticulation code range | ||
L5280, L5301, L5311, L5321, L5331, L5341 | Hemipelvectomy code range | ||
L5400, L5410, L5420, L5430, L5450, L5460 | Immediate post surgical or early fitting procedures code range | ||
L5500, L5505 | Initial, knee prosthesis code range | ||
L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600 | Preparatory prosthesis code range | ||
L5610, L5611, L5613, L5614, L5616, L5617 | Additions: lower extremity code range | ||
L5618, L5620, L5622, L5624, L5626, L5628, L5629 | Additions: test sockets code range | ||
L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653 | Additions: sockets variations code range | ||
L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699 | Additions: socket insert and suspension code range (L5657 New 10/01/2025) | ||
L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707 | Replacement code range | ||
L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783 | Additions: exoskeletal knee-shin system code range | ||
L5785, L5790, L5795 | Component modification code range | ||
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5995, L5999 | Additions: endoskeletal knee-shin system code range | ||
L5858 | Addition to lower extremity prosthesis, endoskeletal knee shin system. microprocessor control feature, stance phase only, includes electronic sensor(s), any type | ||
L5971 | All lower extremity prosthesis, solid ankel cushion heel (sach) foot, replacement only | ||
L5991 | Addition to lower extremity prostheses, osseointegrated external prosthetic connector | ||
L6000, L6010, L6020 | Partial hand code range | ||
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 | ||
L6034 | Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692 | ||
L6038 | Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material | ||
L6039 | Passive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb | ||
L6050, L6055 | Wrist disarticulation code range | ||
L6100, L6110, L6120, L6130 | Below elbow code range | ||
L6200, L6205 | Elbow disarticulation code range | ||
L6250 | Above elbow, molded double wall socket, internal locking elbow, forearm | ||
L6300, L6310, L6320 | Shoulder disarticulation code range | ||
L6350, L6360, L6370 | Interscapular thoracic code range | ||
L6380, L6382, L6384, L6386, L6388 | Immediate post surgical or early fitting procedures code range | ||
L6400 | Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | ||
L6450 | Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | ||
L6500 | Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping | ||
L6550 | Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping | ||
L6570, L6580, L6582, L6584, L6586, L6588, L6590 | Endoskeletal: interscapular code range | ||
L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698 | Additions: upper limb code range | ||
L6700, L6705, L6710, L6711, L6712, L6713, L6714, L6715, L6720, L6721, L6722, L6725, L6730, L6735, L6740, L6745, L6750, L6755, L6765, L6770, L6775, L6780, L6790, L6795, L6800, L6806, L6807, L6808, L6809 | Terminal devices, hooks code range | ||
L6703 | Terminal device, passive hand/mitt, any material any size | ||
L6704 | Terminal device, sport/recreational/work attachment, any material, any size | ||
L6706 | Terminal device, hook, mechanical voluntary opening, any material, any size, line or unline | ||
L6707 | Terminal device, hook, mechanical voluntary closing, any material, any size, line or unlined | ||
L6708 | Terminal device, hand, mechanical, voluntary opening, any material, any size | ||
L6709 | Terminal device, hand, mechanical, voluntary closing, any material, any size | ||
L6805 | Addition to terminal device; modifier wrist unit | ||
L6810 | Addition to terminal device; precision pinch device | ||
L6825, L6830, L6835, L6840, L6845, L6850, L6855, L6860, L6865, L6867, L6868, L6870, L6872, L6873, L6875, L6880 | Terminal devices; hands code range | ||
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 | ||
L6885 | Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power | ||
L6890, L6895 | Terminal devices, gloves for above hands code range | ||
L6900, L6905, L6910, L6915 | Hand restoration code range | ||
L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965 L6970, L6975 | External power, base devices code range | ||
L7007 | Electric hand, switch or myoelectric controlled, adult | ||
L7008 | Electric hand, switch or myoelectric controlled, pediatric | ||
L7009 | Electric hook, switch or myoelectric controlled, adult | ||
L7010, L7015, L7020, L7025, L7030, L7035 | External power, terminal devices code range | ||
L7040 | Prehensile actuator, switch controlled | ||
L7045 | Electronic hook, switch or myoelectric controlled, pediatric | ||
L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7266, L7272, L7274 | External power, elbow code range | ||
L7259 | Electronic wrist rotator, any type | ||
L7360, L7362, L7364, L7366, L7367, L7368, L7499 | External power, battery components code range | ||
L7500, L7510, L7520 | External power, repairs code range | ||
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) | ||
L7402 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular, thoracic, 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 | ||
L7405 | Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material | ||
L7406 | Addition to upper extremity, user adjustable, mechanical, residual limb volume management system | ||
L7600 | Prosthetic donning sleeve, any material, each | ||
L7700 | Gasket or seal, for use with prosthetic socket insert, any type, each | ||
L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049 | General, prosthesis code range | ||
L8300, L8310, L8320, L8330 | General trusses code range | ||
L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8485, L8499 | General, prosthetic sheath/socks code range | ||
L8500, L8501, L8505, L8507, L8509, L8510, L8511, L8512, L8513, L8514, L8515 | Prosthetic implants code range | ||
L8600 | Implantable breast prosthesis, silicone or equal | ||
L8603, L8606 | Prosthetic implants, injectable bulking agent, collagen implant, urinary tract code range | ||
L8609 | Artificial Cornea | ||
L8610 | Ocular implant | ||
L8612 | Aqueous shunt | ||
L8613 | Ossicular implant | ||
L8614 | Cochlear device includes all internal and external components | ||
L8619 | Cochlear implant external speech processor, replacement | ||
L8641 | Metatarsal joint implant | ||
L8642 | Hallux implant | ||
L8670 | Vascular graft material, synthetic, implant | ||
L8699 | Prosthetic implant, not otherwise specified See Policy section for coverage information | ||
Q1001, Q1002, Q1003, Q1004, Q1005 | New technology intraocular lens code range | ||
V2623, V2624, V2625, V2626, V2627, V2628, V2629 | Prosthetic eye code range | ||
V2630, V2631, V2632 | Intraocular lenses code range | ||
ICD-9 Procedure | ICD-10 Procedure | ||
13.91 | Implantation of intraocular telescope prosthesis | 08RJ30Z, 08RK30Z | Replacement of right or left lens with intraocular telescope, percutaneous approach |
95.34 | Ocular prosthetics | F0DZ8UZ | Prosthesis device fitting using prothesis |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
Code appropriate condition |
Code Number | Description | ||
CPT-4 | |||
54400, 54401, 54405 | Penile prosthetic code range | ||
54406 | Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis | ||
54408 | Repair of component(s) of a multi-component, inflatable penile prosthesis | ||
54410 | Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session | ||
54411 | Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue | ||
54415 | Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis | ||
54416 | Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session | ||
54417 | Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same time operative session, including irrigation and debridement of infected tissue | ||
92590, 92591, 92592, 92593, 92594, 92595 | Hearing aid examination and selection code range (Deleted 12/31/2025) | ||
92628,92629,92631,92632,92634,92635,92636,92637,92638,92639,92641,92642 | Hearing aid examination, selection and fitting services code range (New 01/01/2026) | ||
HCPCS | |||
A9282 | Wig, any type, each | ||
E2513 | Accessory for speech generating device, electromyographic sensor | ||
L7900 | Male vacuum erection system | ||
S0618 | Audiometry for hearing aid evaluation to determine the level and degree of hearing loss | ||
V2788 | Presbyopia correcting function of intraocular lens | ||
V5008, V5010, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5095, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5171, V5172, V5181, V5190, V5200, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5266, V5267, V5268, V5269, V5270, V5271, V5272, V5273, V5274, V5275, V5298, V5299 | Hearing services code range | ||
ICD-9 Procedure | ICD-10 Procedure | ||
95.48 | Fitting of hearing aid | F0DZ51Z, F0DZ52Z, F0DZ55Z, F0DZ5KZ, F0DZ5LZ, F0DZ5ZZ | Monaural or binaural hearing aid device fitting using various equipment |
F0DZ51Z, F0DZ52Z, F0DZ55Z, F0DZ5KZ, F0DZ5LZ, F0DZ5ZZ | Assistive listening device, device fitting using various equipment | ||
ICD-9 Diagnosis | ICD-10 Diagnosis |
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