Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Elevated vacuum suspension systems are developed for managing residual limb volume change, minimizing limb movement in the socket, and facilitating perspiration evaporation within the socket. An elevated vacuum suspension system may include the following components: a total surface bearing socket, a gel liner and a vacuum pump.

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.

Billing Codes

HCPCS Codes: L5781 and L5782