License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Lower Limb Prostheses

CMS requires prior authorization of these six lower limb prostheses (LLP) HCPCS codes for all states and territories:

L5856, L5857, L5858, L5973, L5980, and L5987 (functional level 3 or above)

We will base the prior authorization decision on Local Coverage Determination (LCD) L33787 and related Policy Article A52496.

How to Send Your Request

myCGS DME Web Portal with Prior Authorization Smart Submission (PASS) – The fastest, easiest way to send a request and check the status.
Prior Authorization Request Coversheet – Mail, fax, or esMD
Expedited: Send through the myCGS DME Web Portal or use the coversheet to fax or send through esMD.

When to Expect the Decision

We will send a detailed decision letter by the 10th business day following receipt of a request.

Expedited requests: We will review the reason for the expedited request. If we decide there is a valid need for an expedited review, we will make reasonable efforts to send a decision within two days.

Deliver the Prostheses Within 120 Days

Prior authorization decisions for lower limb prostheses will remain valid for 120 calendar days after the provisional affirmation review decision. If the supplier does not deliver the prostheses within 120 calendar days of the decision, the supplier will need to send another prior authorization request.

If the beneficiary needs two items (for example, a foot and knee) that require prior authorization, send one prior authorization request for both codes.

The supplier may send one prior authorization request for both codes. However, we will issue two separate UTNs and two response letters, one for each code. Enter each UTN on the electronic claim 2400 - Service Line for the applicable HCPCs code.

LLP Resources

Top Reasons for Non-Affirmed Decisions

The order was missing or incomplete.
The treating practitioner's order, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity or no medical record documentation was received.
The medical record had an amendment, correction, or delayed entry that does not follow accepted record keeping principles.
There is not a valid handwritten or electronic signature by the author of the medical record.
The medical records do not document the beneficiary's current functional capabilities.

To resolve these errors, review the information published in Supplier Manual Chapter 3 – Supplier Documentation, Local Coverage Determination (LCD) L33787 and related Policy Article A52496.

Updated: 05.30.24

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Lower Limb Prostheses

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