Medicare's Major New Proposal for Prosthetic Coverage

What You Need to Know

Generally speaking the draft LCD takes a whole class of knees and feet that have historically been limited to only K3 patients and proposes giving K2 patients access to those devices subject to certain criteria. For knees, the draft LCD proposes a 2-tiered approach. 

Tier 1: For fluid, pneumatic, and microprocessor-controlled knees previously restricted to only K3 users, the draft proposes permitting these knees to be fit on K2 users when:

1. The beneficiary has had a clinical evaluation to determine their functional level; and,
2. Supporting documentation in the medical record outlines, in the context of the beneficiary’s overall medical health, the rationale for selection of a fluid, pneumatic, or electronic/microprocessor-controlled knee, including (at minimum) how the selected knee will:
   a. Improve the beneficiary’s functional health outcomes (e.g., fall reduction, injury prevention, lower energy expenditure); and,
   b. Help the beneficiary accomplish their activities of daily living (ADLs); and,
3. All lower-level knee systems (e.g., knee systems which exclude use of fluid, pneumatic, or microprocessor) have been considered and ruled out based on the beneficiary’s specific functional and medical needs.

The knee codes eligible for Tier 1 consideration are: L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, and L5858.

Tier 2: For MPK's only, the draft proposes that you must additionally establish that:

1. The electronic/microprocessor knee is indicated for functional level 2; and,
2. The electronic/microprocessor knee has integrated technology that allows the knee to detect when the user trips or stumbles and can automatically adjust to stabilize the knee unit (e.g., stumble recovery); and,
3. The beneficiary is able to make use of a product that requires daily charging; and,
4. The beneficiary is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

The knee codes eligible for Tier 2 consideration are: L5856, L5857, or L5858

The LCD draft additionally proposes that certain foot codes - historically K3 only - could be provided to K2 transfemoral amputees when (a) they satisfy the K2-level criteria listed above for knees, and (b) a higher-level (K3) foot is required for "safe and proper use of the prescribed knee system. " The foot codes eligible for consideration under these criteria are L5973, L5976, L5979, L5980, L5981, and L5987.

What this Means for You

The draft LCD creates a pathway for K2 transfemoral amputees to utilize more functional knee and foot solutions than they have historically had access to. This is a significant positive development. A long-time critique of the K-level classification system has been that it prevents certain patient groups from receiving the prosthetic technologies and related services that might offer the best clinical solutions. This draft LCD is an important step toward addressing historical limitations that have prevented prosthetists from providing the best possible solution for each patient.

On February 22, 2024, CMS will be hosting a national virtual meeting regarding this draft LCD. You can register for that event here.

In addition, you can submit public comments about the draft LCD until March 2, 2024. By clicking on this link, which takes you to the draft LCD and supporting information in its entirety, you can submit public comments by clicking on the "Submit Public Comment" button at the top of the document.

We will keep you posted about any breaking news regarding this draft LCD moving forward.