Medical Necessity for L5000 for missing 4th/5th ray

L5000 is described as a lower limb prosthesis partial foot, toe filler.

The medical necessity for this device, fall under the lower limb prosthesis LCD and does not require the patient to be diabetic to qualify for this prosthesis.

Thus none of the arduous paper work hoops required of the therapeutic shoe program.are you required to jump through in order to qualify the patient and defend your claims in acase of an audit.

What is required is that the chart demonstrate that a prosthesis is required and that the patient can ambulate with the device and that their ambulation will improve. Note I did not say that the patient will improve over time. You should also document that the condition is permanent (unless more toes, rays or a more partial amputation is required). Replacement is based on medical necessity and not the 5 year rule as noted in the AFO/KAFO policy.

In this case, demonstrating that the loss of two metatarsals and toes results in lateral instability must be documented. The patient's increased risk of falling may also be documented but is secondary (but nevertheless important). Providing a plantar lateral carbon plate on the toe filler may address the lateral instability and must be documented in the chart as well as on the order.

As for the shoes and the inserts on the other residual intact limb, those are all covered by the Therapeutic Shoe program and must meet the qualifications of that LCD.

Please note that you cannot provide inserts (A5512-A5514) on the partial foot if you are providing an L5000 on the foot with the missing rays.