Local Coverage Determination · DME MAC
L33787
Lower Limb Prostheses
Version 40. CMS effective date 04/01/2026. CMS updated 04/02/2026. Read from the CMS Coverage API on 2026-10-13. Contractors on the report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
Coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section. The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. Refer to the Supplier Manual for additional information on documentation requirements. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity. A lower limb prosthesis is covered when the beneficiary: Will reach or maintain a defined functional state within a reasonable period of time; and Is motivated to ambulate. A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities.
Excerpt from the LCD indication. Full text on CMS.
Documentation requirements
Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.
Related articles
- A52496 · Lower Limb Prostheses - Policy Article
- A55426 · Standard Documentation Requirements for All Claims Submitted to DME MACs
- A59857 · Response to Comments: Lower Limb Prostheses - DL33787
HCPCS codes on this LCD
201 other Level II codes are on the LCD and are not given a page in this set: L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614….
Questions
What does LCD L33787 cover?
L33787 is Lower Limb Prostheses. It is a current final DME MAC local coverage determination, version 40.
Where is the CMS source for L33787?
The Medicare Coverage Database page for LCD L33787 version 40.
Get the signed answer via API
The signed answer is the receipt for this code on a date of service: the rule that was in force, with a hash you can replay. The call needs an API key. The source archive and as-of resolution are public.
curl -H "X-API-Key: $VERZI_API_KEY" \
"https://api.verzi.health/v1/rules/warrant?hcpcs=L5000&as_of=2024-01-15&npi=1234567890&state=UT"