Coverage of L5859

What You Need to Know:

Medicare created L5859 in 2012 and the code became effective January 1, 2013. Össur was the manufacturer that applied for this code, and Power Knee, which first became commercially available in 2003, was the predicate device for L5859. Some practitioners still shy away from this "new technology," thinking that it is only covered by Worker's Comp plans or the VA, but this is not true. Medicare, Medicare Advantage, some commercial plans, and even some Medicaid plans cover L5859.

The Medicare LCD for Lower Limb Prostheses (L33787) lists 5 separate criteria to establish medical necessity for a powered knee:

1. Has a microprocessor (swing and stance phase type [L5856]) controlled (electronic) knee
2. K3 functional level only
3. 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
4. Is able to make use of a product that requires daily charging
5. Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit

The Lower Limb Prostheses Policy Article (A52496) further expands upon criterion 3, stating "For L5859, the medical records should describe the nature and extent of the comorbidity of the spine or the sound limb which is what is limiting this beneficiary to a household ambulator, and clearly document how this feature will enable the beneficiary to function as a community ambulator."

Although many commercial plans also follow Medicare guidelines, you should always determine the coverage criteria for your patient's specific insurance plan. Most commercial insurance plans post their Medical Policies on their websites, which you can access and review at any time. Insurers usually review these Medical Policies every year, and they periodically change/update criteria.

As with any O&P device, you should not only document the outlined criteria for coverage based on the LCD or medical policy, but also establish medical necessity for the individual patient. That means including a detailed explanation of the patient's comorbidities/clinical needs, and then explaining how the specific features of a powered knee address those needs. This is especially important when upgrading from a patient's current mechanical or microprocessor knee. Your documentation should outline why the current knee is no longer appropriate for the patient/what issues it is causing the patient, and then address how a powered knee will resolve those specific problems. You want to make sure you are not just listing the knee's benefits, but creating a comprehensive argument that explains why a powered knee is the most appropriate knee available for this specific patient.

What This Means for You:

More and more health plans are approving powered knees for patients when medical necessity is established. If you have a patient that you believe would benefit from this kind of device, always review the applicable Medical Policy to gain a better understanding of the coverage criteria. Even if a particular insurance company did not cover a powered knee in the past, their policy may have changed since you last checked. It is important that you always review the most updated version of the Medical Policy for your patients' health plan to determine current coverage criteria, which you can typically find on the insurance company's website. And even if the policy states that a powered knee is "experimental/investigational," you can still obtain an approval. Although the insurer will initially deny these authorization requests, comprehensive documentation along with a thorough appeal specifically rebutting the claim that powered knees are experimental can overturn the initial decision.