Blue Cross updates its microprocessor-controlled knee medical policy

Blue Cross Blue Shield of Michigan updated its medical guidelines for its Microprocessor-Controlled Prostheses and Orthoses for the Lower Limb Policy, effective Sept. 1, 2020.

This update is for the following HCPCS codes:

• L5856
• L5857
• L5858
• L5973
• L2006

A microprocessor-controlled knee may be considered established in individuals with transfemoral amputation who meet all the following requirements:

• Demonstrated need for long distance ambulation at variable rates (use of the limb in the home or for basic community ambulation isn’t sufficient to justify provision of the computerized limb over standard limb applications) or demonstrated patient need for regular ambulation on uneven terrain or for regular use on stairs (Use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application.)
• Physical ability, including adequate cardiovascular and pulmonary reserve, for ambulation at faster than normal walking speed
• Adequate cognitive ability to master use and care requirements for the technology

A microprocessor-controlled knee is considered established when individuals meet the below criteria.
A powered knee is considered experimental.

A microprocessor-controlled knee-ankle-foot, or KAF, device (e.g., Ottobock C-Brace™ Orthotronic Mobility System, Ottobock the Sensor Walk™ stance control KAFO) is considered experimental.

Inclusionary and exclusionary guidelines

Patient selection and identification

For patients in whom the potential benefits of the microprocessor knees are uncertain, patients may first be fitted with a standard prosthesis to determine their level of function with the standard device.

1. Contraindications for the use of the microprocessor knee should include the following:
   • Any condition that prevents socket fitting, such as a complicated wound or intractable pain that precludes socket wear
   • Inability to tolerate the weight of the prosthesis
   • Medicare level K0  —  No ability or potential to ambulate or transfer
   • Medicare level K1  —  Limited ability to transfer or ambulate on level ground at fixed cadence
   • Medicare level K2  —  Limited community ambulator who doesn’t have the cardiovascular reserve, strength and balance to improve stability in stance to permit increased independence, less risk of falls and potential to advance to a less restrictive walking device
   • Inability to use swing and stance features of the knee unit
   • Poor balance or ataxia that limits ambulation
   • Significant hip flexion contracture (greater than 20 degrees)
   • Significant deformity of remaining limb that would impair the ability to stride
   • Limited cardiovascular or pulmonary reserve or profound weakness
   • Limited cognitive ability to understand gait sequencing or care requirements
   • Long distance or competitive running
   • Falls outside of recommended weight or height guidelines of the manufacturer
   • Specific environmental factors, such as excessive moisture or dust, or inability to charge the prosthesis
   • Extremely rural conditions where maintenance ability is limited
2. Indications for the use of the microprocessor knee should include the following:
   • Adequate cardiovascular and pulmonary reserve to ambulate at variable cadence
   • Adequate strength and balance in stride to activate the knee unit
   • Shouldn’t exceed the weight or height restrictions of the device
   • Adequate cognitive ability to master technology and gait requirements of the device
   • Hemi-pelvectomy through knee-disarticulation level of amputation, including bilateral; lower-extremity amputees are candidates if they meet functional criteria as listed
   • The patient is an active walker and requires a device that reduces energy consumption to permit longer distances with less fatigue
   • Daily activities or job tasks that don’t permit full focus of concentration on knee control and stability, such as uneven terrain, ramps, curbs, stairs, repetitive lifting or carrying
   • Medicare level K2  —  Limited community ambulator, but only if improved stability in stance permits increased independence, less risk of falls and potential to advance to a less restrictive walking device, and the patient has cardiovascular reserve, strength and balance to use the prosthesis. The microprocessor enables fine-tuning and adjustment of the hydraulic mechanism to accommodate the unique motor skills and demands of the functional level K2 ambulator.
   • Medicare level K3  —  Unlimited community ambulator
   • Medicare level K4  —  Active adult, athlete who needs to function as a K3 level in daily activities
   • Potential to lessen back pain by providing more secure stance control, using less muscle control to keep the knee stable
   • Potential to unload and decrease stress on remaining limb
   • Potential to return to an active lifestyle
3. Physical and functional fitting criteria for new amputees:
   • New amputees may be considered if they meet certain criteria as outlined above
   • Premorbid and current functional assessment important determinant
   • Requires stable wound and ability to fit the socket
   • Must have potential to return to an active lifestyle

The above guidelines come from the Veterans Health Administration Prosthetic Clinical Management Program Clinical Practice Recommendations for Microprocessor Knees (Berry, 2000).