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Linda Collins Blogger

Lower Limb Prosthetic Covers

Posted by Linda Collins | November 02, 2016

​The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have received a high volume of submitted claims for lower limb prosthetic covers (L5704-L5707) and protective covering systems (L5962, L5964, and L5966) for the same lower limb prosthesis. The need for both of these is rare. Coverage of lower limb prosthetic covers list specific medical necessity requirements. Your records must document the reason for the cover and the specific uses.

Lower limb prosthetic covers (L5704–L5707) offer shape, protection and waterproofing for normal daily usage of a lower limb prosthesis.  According to the DME MACs, these covers offer sufficient protection and weatherproofing for prosthetic devices.

Protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. According to the DME MACS, these systems are used for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of that which is afforded by L5704-L5707. The coverage requirements make it clear these protective outer surface coverage systems are not covered for cosmetic or convenience reasons, or for everyday usage in a typical environment. An article published by the Medicare Pricing, Data Analysis and Coding Contractor (PDAC), states this type of extra protection is not routinely necessary and are rarely covered.

What does this mean for you?

When providing lower limb prosthesis covers be sure to document the medical necessity. If you do have a patient requiring a protective outer surface covering system, make sure your notes and the physician's notes detail the extraordinary circumstances and environmental conditions present. In the absence of these conditions, you may choose to use an ABN and notify the patient in advance of possible medical necessity denial.

Read the entire PDAC article here

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