Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Traumatic amputation at level between knee and ankle, right lower leg

Treatment: Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side)

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side)

The denial is overturned

The patient has a past medical history of complete traumatic amputation at the level between the knee, ankle, and right lower leg.  The patient presented for a prosthetic evaluation.  The records indicated that the patient was a K3 (ability/ability to ambulate) ambulator.  The patient reported he had been active with the below the knee prosthesis since childhood without issues.  The current socket was greater than 10 years old and was worn out and torn.  Recently, the socket was cracked beyond repair while riding a bicycle.  The liners and socks were worn and torn.  The foot/ankle was also worn.  The patient had been using his spare while the main unit was in disrepair.  The patient was working in sales full-time.  The patient exercised regularly with walking and biking.  The Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side) was provided to the patient.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side), provided needs final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side.

The Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side), is the best available treatment for this patient at this time

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. There are no adverse risks. 

The patient is an active individual and therefore requires a prosthesis to fit his lifestyle and function.  His current prosthesis can lead to issues of skin breakdown, instability and infection. The noted requests do address the issues of moisture as well as increase stability and create a better fit without any significant risks.

The insurer's denial of coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 (additional to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system)- modifier RT (right side) is overturned.