Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: traumatic amputation

Treatment: Healthcare Common Procedure Coding System (HCPCS) code L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system with Modifier LT left side

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system with Modifier LT left side

The denial is upheld.

This case involves an adult male with a left lower extremity amputation who was recommended coverage for code L5781 (Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system) with Modifier LT [left side (used to identify procedures performed on the left side of the body)].  The documentation submitted for the review noted that an artificial leg was approved for the patient but that a vacuum socket was not shown to be safe and effective among amputees due to insufficient evidence of safety and/or efficacy.  The patient's plan therefore does not cover services that have not shown to be helpful.  The patient's diagnosis was complete traumatic amputation between the knee and ankle of the left leg. Records stated the patient received in addition to the lower limb prosthesis, vacuum pump, for residual limb volume management and moisture evacuation.  This was the denied service, which was now being appealed by the treating physician.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

The Healthcare Common Procedure Coding System (HCPCS) code L5781 needs final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for Healthcare Common Procedure Coding System (HCPCS) code L5781.

Healthcare Common Procedure Coding System (HCPCS) code L5781 is not the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatments/services.

Based on the provided information, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

Current literature mentions that despite positive recommendations, vacuum-assisted suspension sockets are not universally indicated and awareness and compliance is often required from the user of the device before authorization can be given. The treating physician will need to specify how this system will be of benefit over a standard prosthetic device for this patient.  

In summary, the denial of Healthcare Common Procedure Coding System (HCPCS) code L5781 (Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system) with Modifier LT [left side (used to identify procedures performed on the left side of the body)] and coverage for the requested service/treatment should be upheld. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.