REVIEW REQUEST FOR
Microprocessor Controlled Lower Limb Prosthesis
Provider Data Collection Tool Based on Medical Policy OR-PR.00003
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/13/2015
Provider Tool Effective Date: 01/13/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) ( if known):
This provider tool is for requested authorization for microprocessor controlled lower limb prostheses including, but not limited
to, knee prosthesis (such as the Otto-Bock C-Leg device®, the Genium™ Bionic Prosthetic System, the Ossur RheoKnee®, and
the Endolite Intelligent Prosthesis®) and foot-ankle prosthesis (such as the Proprio Foot® and the PowerFoot BiOM).
Please check all that apply to the individual:
Request is for microprocessor controlled lower limb prosthesis: (Check all that apply)
Otto-Bock C-Leg device®
Otto-Bock GeniumTM Bionic Prosthetic System
Ossur RheoKnee®
Endolite Intelligent Prosthesis®
Other microprocessor controlled lower limb prosthesis (Please List):
Proprio Foot®
PowerFoot BiOM
Other microprocessor controlled foot-ankle prosthesis (Please List):
Individual has transfemoral (above knee) amputation
Individual has knee disarticulation amputation
Other (Please List):
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REVIEW REQUEST FOR
Microprocessor Controlled Lower Limb Prosthesis
Provider Data Collection Tool Based on Medical Policy OR-PR.00003
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/13/2015
Provider Tool Effective Date: 01/13/2015
Individual has an adequate cardiovascular reserve and cognitive learning ability to master the higher level technology and
to allow for faster than normal walking speed
Individual has demonstrated the ability to ambulate faster than their baseline rate using a standard prosthetic application
with a swing and stance control knee
Documented need for daily long distance ambulation (for example, greater than 400 yards) at variable rates
Need is limited to use within the home or for basic community ambulation
Demonstrated need for regular ambulation on uneven terrain or regular use on stairs
Need is limited to stair climbing in the home or place of employment
Undergone complete multidisciplinary assessment including an evaluation by a trained prosthetic clinician****
**** The complete multidisciplinary assessment must also accompany this document. Please attach.****
Other (Please List):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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