Washington L&I uses this request to decide whether to authorize a new, repaired or replacement prosthesis for an injured worker, one device per request. The clinician documents amputation level and residual limb condition, upper or lower extremity function, K-level and strength for leg prostheses, work and mobility demands, prior devices, and the HCPCS components requested with cost and medical necessity.
The prosthetic clinician completes all sections, names the attending provider, signs, and attaches residual limb measurements and warranty information. L&I's Occupational Nurse Consultant completes the authorization block.
Download the current version from the source each time; forms change without notice.
Labor and Industries Prosthetic Device Request Form
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No. The form header states one prosthetic device per request. A secondary prosthesis or a replacement needs its own request, and section 5 asks for the necessity and purpose of a secondary device, prior device history and the reason for any change from an exact replacement.
Complete the Microprocessor Knee Request Addendum. It asks whether a physician specializing in amputee rehabilitation made the recommendation, how the K-level was derived, prosthetist access, trial results with a gait description, hip flexion contracture under 20 degrees and agreement to the manufacturer's weight and environment limits.