The four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have jointly published an updated version of the Lower Limb Prostheses Local Coverage Determination (LCD) that adds language denying coverage of code L-5969 (Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)). Medicare created L-5969 in December 2013 for the iWalk BiOM motor-powered prosthetic foot-ankle. The language added to the LCD reads as follows:
“The microprocessor foot or ankle system addition with power assist which includes any type motor (L-5969) is not covered because there is insufficient information to demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM [Program Integrity Manual] Chapter 13. Claims for L-5969 will be denied as not reasonable and necessary.
“Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the physician’s or prosthetist’s files.”
The update is effective retroactively to January 1, 2014.