Does S78.119D require prior authorization?

No, S78.119D does not require prior authorization (high confidence). Covered without prior authorization.

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`S78.119D`, Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

ICD-10-CM diagnosis code(s) documenting the current or past pressure ulcer as listed in the policy's "ICD-10-CM Diagnosis Codes That Support Medical Necessity" section
Clinical documentation in the medical record verifying presence or history of a pressure ulcer and its location corresponding to the seating contact area
Comprehensive, written evaluation by a licensed/certified medical professional (PT or OT) that clearly explains why a prefabricated seating system is not sufficient to meet seating and positioning needs.

Key Coverage Criteria

Microprocessor controlled knee prostheses are consideredmedically necessaryfor individuals with transfemoral (above knee) and knee disarticulation amputations whenallof the criteria set forth in (A) and (B) below have been met:Selection criteria:Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;andIndividual has a functional K-Level 3 or above;andThe provider has documented that there is a reasonable likelihood of better mobility [...]
Selection criteria:Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;andIndividual has a functional K-Level 3 or above;andThe provider has documented that there is a reasonable likelihood of better mobility or stability with the device instead of a mechanical knee prosthesis;andThere is documented need for ambulation in situations where the device will provide benefit (for example, regular need to ascend/descend stairs, traverse u [...]
Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology;and
Individual has a functional K-Level 3 or above;and
The provider has documented that there is a reasonable likelihood of better mobility or stability with the device instead of a mechanical knee prosthesis;and
There is documented need for ambulation in situations where the device will provide benefit (for example, regular need to ascend/descend stairs, traverse uneven surfaces or ambulate for long distances [generally 400 yards or greater cumulatively]);and

`S78.119D`, Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

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S78.119D, Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

2 Active Policies

Related Codes

Have a follow-up question?

`S78.119D`, Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter