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L5626

Lower Limb Prostheses

LCD L33787 · CMS's HCPCS descriptor for L5626: Addition to lower extremity, test socket, hip disarticulation.

Not on CMS's Required Prior Authorization List for DMEPOS on 2026-10-13. source

LCD L33787 · 27 versions, 2015 to today · last changed 2026-04-01 (R14)

Version 17 of LCD L33787: in force by CMS's dates 2018-11-01 to 2019-12-31. The policy text on this page comes from this archived version. On its start date, 2018-11-01, the companion Articles in force were Article A52496 version 12 and Article A55426 version 50. Verzi cannot say which version of Article A59857 was in force on that date.

DME MAC jurisdictions
JA · Noridian 16013
CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT
JB · CGS 17013
IL, IN, KY, MI, MN, OH, WI
JC · CGS 18003
AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, WV
JD · Noridian 19003
AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, NE, NV, ND, MP, OR, SD, UT, WA, WY
source

CMS's Who are the MACs jurisdiction pages (DME facts as of 2025-09-30) name each contractor and its states; the MCD's Contractor Information table on every DME LCD prints the contract numbers. Both read 2026-10-09. Verzi adds the state lookup only.

You are viewing version 17 (2018-11-01 to 2019-12-31). Version 40 is in force today.

Codes CMS lists in this LCD's current version (version 40, 206 codes). CMS's download carries no list for version 17: L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5410 L5420
182 more codes
L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5615 L5616 L5617 L5618 L5620 L5622 L5624 L5626 L5628 L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5639 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656 L5657 L5658 L5661 L5665 L5666 L5668 L5670 L5671 L5672 L5673 L5676 L5677 L5678 L5679 L5680 L5681 L5682 L5683 L5684 L5685 L5686 L5688 L5690 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5700 L5701 L5702 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5712 L5714 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782 L5783 L5785 L5790 L5795 L5810 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5827 L5828 L5830 L5840 L5841 L5845 L5848 L5850 L5855 L5856 L5857 L5858 L5859 L5910 L5920 L5925 L5926 L5930 L5940 L5950 L5960 L5961 L5962 L5964 L5966 L5968 L5969 L5970 L5971 L5972 L5973 L5974 L5975 L5976 L5978 L5979 L5980 L5981 L5982 L5984 L5985 L5986 L5987 L5988 L5990 L5991 L5992 L5999 L7367 L7368 L7510 L7520 L7600 L7700 L8400 L8410 L8417 L8420 L8430 L8440 L8460 L8470 L8480

Sections in this version: Coverage Indications, Limitations, and/or Medical Necessity · Coding Information · Associated Information · Sources of Information. Plus 4 sections marked N/A in this version.

Full verbatim text serves to customers · Customer? Log in

Version history, LCD L33787

CMS numbers each version. Each box shows the version's window by CMS's stated dates. Select a version to show it on this page. Versions superseded the same day they took effect never governed a claim, so the page hides them until you ask. Version numbers CMS never published to its archive do not exist as documents.

v22015-10-01, superseded same dayv22015-10-01, superseded same dayv52015-10-01, superseded same dayv52015-10-01, superseded same dayv62015-10-01, superseded same dayv62015-10-01 to 2016-06-30v92016-07-01, superseded same dayv92016-07-01 to 2016-12-31v112017-01-01, superseded same dayv112017-01-01 to 2017-12-31v132018-01-01, superseded same dayv132018-01-01 to 2018-10-31v172018-11-01, superseded same dayv172018-11-01 to 2019-12-31v222020-01-01, superseded same dayv222020-01-01 to 2023-09-30v242023-10-01, superseded same dayv242023-10-01 to 2023-12-31v262024-01-01, superseded same dayv262024-01-01 to 2024-03-31v292024-04-01, superseded same dayv292024-04-01 to 2024-08-31v332024-09-01, superseded same dayv332024-09-01 to 2025-03-31v352025-04-01 to 2025-09-30v382025-10-01 to 2026-03-31v402026-04-01 to today

Revision history, every version

CMS's own change log, quoted, 23 entries. It does not change with the version shown. A revision (R-number) is a change CMS logged. The version (vN) is the snapshot that carries it.

R14 · 2026-04-01 · v40
Revision Effective Date: 04/01/2026
HCPCS CODES:
Added: L5992 to Group 1 Codes


04/09/2026: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R13 · 2025-10-01 · v38
Revision Effective Date: 10/01/2025
HCPCS CODES:
Added: HCPCS code L5657
Revised: Long descriptions of HCPCS codes L5673, L5679, and L5783
10/23/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R12 · 2025-04-01 · v35
Revision Effective Date: 04/01/2025
SUMMARY OF EVIDENCE:
Removed: Summary of evidence information, due to not being applicable to the non-discretionary changes
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Removed: Analysis of evidence information, due to not being applicable to the non-discretionary changes
HCPCS CODES:
Added: HCPCS code L5827
BIBLIOGRAPHY:
Removed: Bibliography information, due to not being applicable to the non-discretionary changes
04/03/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R11 · 2024-09-01 · v33
Revision Effective Date: 09/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Coverage criteria for microprocessor-controlled ankle foot system, energy storing foot, dynamic response foot with multi-axial ankle, flex foot system, flex-walk system or equal, and shank foot system with vertical loading pylon, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
Revised: Coverage criteria for a fluid or pneumatic knee unit, control addition fluid, and electronic/microprocessor-controlled knee system, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
SUMMARY OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
ANALYSIS OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
BIBLIOGRAPHY:
Added: Information related to microprocessor-controlled prosthetic knees
CODING INFORMATION:
Added: GA, GY, GZ, and KX modifiers
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments article (A59857)
R11 · 2024-09-01 · v33
Revision Effective Date: 09/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Coverage criteria for microprocessor-controlled ankle foot system, energy storing foot, dynamic response foot with multi-axial ankle, flex foot system, flex-walk system or equal, and shank foot system with vertical loading pylon, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
Revised: Coverage criteria for a fluid or pneumatic knee unit, control addition fluid, and electronic/microprocessor-controlled knee system, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
SUMMARY OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
ANALYSIS OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
BIBLIOGRAPHY:
Added: Information related to microprocessor-controlled prosthetic knees
CODING INFORMATION:
Added: GA, GY, GZ, and KX modifiers
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments article (A59857)
R10 · 2024-04-01 · v29
Revision Effective Date: 04/01/2024
HCPCS CODES:
Added: HCPCS codes L5841 and L5783
05/02/2024: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R10 · 2024-04-01 · v29
Revision Effective Date: 04/01/2024
HCPCS CODES:
Added: HCPCS codes L5841 and L5783
05/02/2024: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R9 · 2024-01-01 · v26
Revision Effective Date: 01/01/2024
HCPCS CODES:
Added: HCPCS codes L5615 and L5926
12/28/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R9 · 2024-01-01 · v26
Revision Effective Date: 01/01/2024
HCPCS CODES:
Added: HCPCS codes L5615 and L5926
12/28/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R8 · 2023-10-01 · v24
Revision Effective Date: 10/01/2023
HCPCS CODES:
Added: HCPCS code L5991
12/14/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R8 · 2023-10-01 · v24
Revision Effective Date: 10/01/2023
HCPCS CODES:
Added: HCPCS code L5991
12/14/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.
R7 · 2020-01-01 · v22
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: “physician” to “practitioner”
Revised: “physician’s” to “treating practitioner’s”
Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
DOCUMENTATION REQUIREMENTS:
Revised: “physician's” to “treating practitioner's”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO

03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).
R7 · 2020-01-01 · v22
Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: “physician” to “practitioner”
Revised: “physician’s” to “treating practitioner’s”
Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
DOCUMENTATION REQUIREMENTS:
Revised: “physician's” to “treating practitioner's”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO

03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).
R6 · 2018-11-01 · v17
Revision Effective: 11/01/2018


Coverage Indications, Limitations, and/or Medical Necessity:


Removed: Weight range information related to L5859.


11/01/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
R6 · 2018-11-01 · v17
Revision Effective: 11/01/2018


Coverage Indications, Limitations, and/or Medical Necessity:


Removed: Weight range information related to L5859.


11/01/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
R5 · 2018-01-01 · v13
Revision Effective: 01/01/2018


HCPCS CODES:


Added: L7700 to Group 1 Codes per annual HCPCS code release


12/21/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
R5 · 2018-01-01 · v13
Revision Effective: 01/01/2018


HCPCS CODES:


Added: L7700 to Group 1 Codes per annual HCPCS code release


12/21/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
R4 · 2017-01-01 · v11
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: PIM reference under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
R4 · 2017-01-01 · v11
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: PIM reference under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
R3 · 2016-07-01 · v9
Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.
R3 · 2016-07-01 · v9
Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.
R2 · 2015-10-01 · v6
Revision Effective Date: 10/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: Standard language regarding Medicare coverage
HCPCS CODING:
Revised: HCPCS Narrative of L7367
DOCUMENTATION REQUIREMENTS:
Added: Continued need, continued use, and Prior Payer verbiage and updated standard language documentation
Revised: Repair/Replacement verbiage
R2 · 2015-10-01 · v6
Revision Effective Date: 10/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: Standard language regarding Medicare coverage
HCPCS CODING:
Revised: HCPCS Narrative of L7367
DOCUMENTATION REQUIREMENTS:
Added: Continued need, continued use, and Prior Payer verbiage and updated standard language documentation
Revised: Repair/Replacement verbiage
Receipts for auditors

Version 17 of LCD L33787, shown on this page: in force by CMS's dates 2018-11-01 to 2019-12-31. Archived 2026-10-02. CMS's copy · Our archived file. 8 of 8 sections are proven word-identical to the archived file.

Every archived version of LCD L33787 (27 versions, CMS's dates, window by the as-of rule).

DocumentVersionIn forceArchived onVerify
LCD L33787version 22015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 22015-10-01, superseded same day2026-10-02CMS's copy · Our archived file
LCD L33787version 52015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 52015-10-01, superseded same day2026-10-02CMS's copy · Our archived file
LCD L33787version 62015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 62015-10-01 to 2016-06-302026-10-02CMS's copy · Our archived file
LCD L33787version 92016-07-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 92016-07-01 to 2016-12-312026-10-02CMS's copy · Our archived file
LCD L33787version 112017-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 112017-01-01 to 2017-12-312026-10-02CMS's copy · Our archived file
LCD L33787version 132018-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 132018-01-01 to 2018-10-312026-10-02CMS's copy · Our archived file
LCD L33787version 172018-11-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 17 shown2018-11-01 to 2019-12-312026-10-02CMS's copy · Our archived file
LCD L33787version 222020-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 222020-01-01 to 2023-09-302026-10-02CMS's copy · Our archived file
LCD L33787version 242023-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 242023-10-01 to 2023-12-312026-10-02CMS's copy · Our archived file
LCD L33787version 262024-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 262024-01-01 to 2024-03-312026-10-02CMS's copy · Our archived file
LCD L33787version 292024-04-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 292024-04-01 to 2024-08-312026-10-02CMS's copy · Our archived file
LCD L33787version 332024-09-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33787version 332024-09-01 to 2025-03-312026-10-02CMS's copy · Our archived file
LCD L33787version 352025-04-01 to 2025-09-302026-10-02CMS's copy · Our archived file
LCD L33787version 382025-10-01 to 2026-03-312026-10-09CMS's copy · Our archived file
LCD L33787version 402026-04-01 to today2026-09-26CMS's copy · Our archived file

The related Articles each have their own receipts: Article A52496 · Article A55426 · Article A59857.

Each archived file's page gives its sha256 fingerprint. A copy of the file hashes to the same value, byte for byte.

CMS's live page shows only the current version. To check a passage by eye, open CMS's copy of the same version number. A version's window ends on the earlier of CMS's stated end date and the day before the next version starts.

Every policy word on this page is CMS's, from the archived version named beside it. Verzi adds labels, highlights, citations and links only. Verzi-written summary content on this page: none.

Governing policies, as CMS lists them:

From CMS's LCD code table. HCPCS Level II codes only.

source

CMS's LCD code table in the Medicare Coverage Database download, archived 2026-10-09: Our archived file.

Watch L5626

One email when any policy cited for L5626 changes or gains a future effective date. Nothing else, ever.