Documentation for Lower Limb Prosthesis

by  Medicare Learning Network
March 8th, 2018

The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:

Reasons for Denial – Insufficient Documentation

For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.

For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s medical condition(s) that requires the use of the specifically ordered lower limb prosthetic as well as beneficiary’s medical condition(s) that would impact the beneficiary’s ability to effectively utilize the specifically ordered lower limb prosthetic in achieving a defined functional state. The medical record is not limited to physician’s office records but may include:

The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) received a high volume of submitted claims for lower limb prosthetic covers and protective covering systems for the same lower limb prosthesis. The need for both of these is rare. (For details refer to .)

To Prevent Denials

A medical necessity determination for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

Base clinical assessments of beneficiary rehabilitation potential on the following classification levels:

The records must contain documentation on the beneficiary’s current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.


Documentation for Lower Limb Prosthesis. (2018, March 8). Find-A-Code Articles. Retrieved from

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