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 regarding the denial of 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 (used to identify procedures performed on the left side of the body)].  

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

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)] 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) 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 treatment/services.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient at this time.

Current literature states that lower limb amputation has a major functional impact and significantly reduces independence in daily life. An adequate socket fit on the residual limb is essential to ensure the patient's comfort but may be impeded by stump volume variations. Movements of the residual limb in the socket may lead to pain, sores, poor prosthesis control, or simply lack of comfort resulting in a limitation of prosthesis use and a loss of mobility. Fifty-seven percent of the amputee population are dissatisfied with the comfort of their prostheses and this lack of comfort represents the main complaints in amputees.  Vacuum-assisted suspension systems (VASS) (or elevated vacuum systems or active vacuum systems) draw out air and create a negative pressure at the residual limb liner and socket interface.  The patient has a left lower extremity amputation below the knee and was authorized for a prosthetic device.  

The documentation provided for the review noted the patient has a residual limb following traumatic amputation of the left lower extremity between the knee and ankle area.  The patient was approved for a prosthetic device but received a denial for coverage of HCPS code L5781.  The treating physician did not elaborate on why the patient was being recommended for this specific prosthetic device.  

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 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.