Does K1007 require prior authorization?

Yes, K1007 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`K1007`, Bilateral hip, knee, ankle, foot device, powered, includes pelvic component,

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

Product information (manufacturer, part number or part name) for prosthetic components must be recorded in the medical records.
For K3 or above functional levels, a documented evaluation from a physical therapist establishing the functional level and activities is required.
There must be documentation of the member’s history and current condition that supports the designation of the functional level by the prosthetist and physical therapist.

For billing certain HCPCS (per CMS policy), a written Coding Verification Review (CVR) by PDAC must have been obtained for the product; information concerning documentation to submit to PDAC and the PDAC Product Classification List should be referenced and relevant PDAC documentation retained.

Key Coverage Criteria

Orthosis and/or prosthesis is medically necessary when: care is prescribed by a physician, nurse practitioner, podiatrist or other health professional qualified to prescribe orthotics/prosthetics under State law; the orthosis/prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADLs); the member’s participating physician or licensed health care practitioner has determined the orthosis/prosthesis will allow the member to p [...]
Lower limb prosthesis is medically necessary when: member is motivated to ambulate; member meets the specific criteria for lower limb prostheses set forth in the policy; and member will reach or maintain a defined functional state within a reasonable period of time.
Prostheses are considered medically necessary only for functional classification levels K1 and above for certain components and higher K-levels for more advanced components (see device-specific indications below).
Foot prostheses: SACH foot is medically necessary for persons whose functional level is K1 or above.
Foot prostheses: External keel SACH foot or single axis ankle/foot is medically necessary for persons whose functional level is K1 or above.
Foot prostheses: Flexible-keel foot or multi-axial ankle/foot is medically necessary for persons whose functional level is K2 or above.

9 Active Policies

ANTHEM-MP-C176719, OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

EVICORE-HPLAN-CIGNA-3C6BF790C032, Cigna Commercial DME Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

AETNA-CPB-0578, Lower Limb Prostheses

BCBSIL-DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

BCBSMT-DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

BCBSNM-DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

BCBSOK-DME103.008, Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

REGENCE-DME89, Powered Exoskeleton for Ambulation and Rehabilitation

`K1007`, Bilateral hip, knee, ankle, foot device, powered, includes pelvic component,

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

K1007, Bilateral hip, knee, ankle, foot device, powered, includes pelvic component,

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

`K1007`, Bilateral hip, knee, ankle, foot device, powered, includes pelvic component,