Elevated Vacuum Suspension Systems

Coverage Decision: Covered with conditions

Conditions of Coverage

  • The worker must have a transtibial amputation allowed on the claim, and
  • Recommendation comes from a physician (MD or DO) who specializes in functional rehabilitation of amputees, and
  • The worker must meet the threshold of a community ambulatory (able or anticipated to walk with a prosthesis at least 1450 steps/day), and
  • There is clinical rationale or experience that a conventional socket is inadequate, and
  • The conventional socket, if applicable, cannot be modified to adequately secure the limb to the prosthesis.

 

Implementation of the Coverage Decision

The device may be used only for care of a condition accepted on the claim.  All requests for an elevated vacuum suspension system require prior authorization.

For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultant and claims manager.

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Billing Codes
HCPCS Codes: L5781 and L5782

 


For more information:
Contact information.


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