Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-9
Topic: Screening List For Prosthetic Devices
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Prosthetic devices (other than dental) that replace all or part of a body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning body organ are covered when furnished on a physician's order. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the medical record, including the judgment of the attending physician, indicates the condition will be of long and indefinite duration, the test of permanence will be considered met.

Prosthetic devices dispensed to a patient prior to performance of the procedure that will necessitate use of the device are not covered. Dispensing a prosthetic device in this manner would not be considered reasonable and necessary for the treatment of the patient's condition.

Claims for prosthetic devices listed on the Table Attachment below should be processed as indicated for each item.

Coverage for Prosthetics and Orthotics is determined according to individual or group customer benefits.

DLR - Date Last Reviewed


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

A4310A4311A4312A4313A4314A4315
A4316 A4320 A4321A4322A4326A4327
A4328 A4331A4332A4333A4334A4335
A4338A4340A4344 A4346A4348A4349
A4351A4352A4353A4354A4355A4356
A4357A4358A4359A4361A4362A4365
A4366A4367A4368A4369A4371A4372
A4373A4375A4376A4377A4378A4379
A4380A4381A4382A4383A4384A4385
A4387A4388A4389A4390A4391A4392
A4393A4394A4395A4396A4397A4398
A4399A4400A4402A4404A4405A4406
A4407A4408A4409A4410A4413A4414
A4415A4416A4417A4418A4419A4420
A4421A4422A4423A4424A4425A4426
A4427A4428A4429A4430A4431A4432
A4433A4434A4481A4483A4520A4554
A4605A4623A4624A4625A4626A4629
A5051A5052A5053A5054A5055A5061
A5062A5063A5071A5072A5073A5081
A5082A5093A5102A5105A5112A5113
A5114A5119A5121A5122A5126A5131
A5200A7501A7502A7503A7504A7505
A7506A7507A7508A7509A7520A7521
A7522A7523A7524A7525A7526A7527
D5110D5120D5130D5140D5225D5226
E1399E0740S8189   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. The bladder stimulator (pacemaker) and electrical continence aids are considered eligible services when determined medically necessary based on the patient’s condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/2002, Non-implantable pelvic floor electrical stimulators
10/2002, Blue Shield revises coverage guidelines for urinary catheters

References

MCM 2130

MCIM 60-24, 65-2, 65-5, 65-9, and 65-11

Medicare National Coverage Decision 230.15

View Previous Versions

No Previous Versions

Table Attachment

Screening List for Prosthetic Devices
Item Coverage Status

Bladder stimulator (Pacemaker)
DLR - 07/2004
Deny-experimental/investigational. Scientific evidence does not demonstrate the safety of this device. In addition, there are no long-term studies available.

Catheters and Cunningham clamps
See urinary collection system.

Dentures (D5110-D5140, D5225, D5226)
Excluded from coverage.

Electrical continence aids
DLR - 10/2004
Deny-experimental/investigational. Scientific evidence does not demonstrate the safety and effectiveness of this device.

Electronic speech aids
Covered for post-laryngectomy patients or patients with a permanently inoperative larynx.

Mechanical/hydraulic incontinence aids
Covered for patients with permanent anatomic and neurological dysfunctions of the bladder.

Non-implantable pelvic floor electrical stimulator (E0740)
Covered for the treatment of stress and/or urge urinary incontinence. (625.6, 788.31, 788.33).

Patients must be cognitively intact and have failed a documented trial of pelvic muscle exercise (PME) training. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing four weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

Obturator
See Medical Policy Bulletin S-29

Ostomy care supplies (e.g., Hollister)(A4361-A4362, A4365-A4434, A5051-A5093, A5119-A5131, A5200)
Covered for ostomy patients.
NOTE:
Payment may be made for skin barrier codes A4362, A4372, A4373, A4385, A4407-A4410, A4414, A4415, A5121, and A5122 only when used for ostomy patients. When these skin barrier codes are used for other conditions (e.g., permanent urinary incontinence), they should be denied as not covered. A participating, preferred, or network provider can bill the member for the denied service.
NOTE:
An ostomy pouch cover is non-medical in nature. Therefore, it will be denied as not covered. A participating, preferred, or network provider can bill the member for the denied service.
NOTE:
For information on skin prep supplies (A4365, A4369, A4371, A4405, A4406, A5119) used for diabetics, see Medical Policy Bulletin E-15.

Phrenic nerve stimulator
Covered for patients with partial or complete respiratory insufficiency.

See Medical Policy Bulletin Z-7 for information on implantation of a phrenic nerve stimulator.

Silastic gel implant
Covered as a urinary incontinence aid.

Speech Processor
Does not meet the definition of a prosthetic device. See Medical Policy Bulletin S-67, Cochlear Implantation, for information on speech processors as part of a cochlear implant. See Medical Policy Bulletin E-36 for information on speech generating devices.

Trachea supplies (A4421, A4481, A4483, A4605, A4623-A4626, A4629, A7501-A7509, A7520-A7527, S8189)
Covered for tracheostomy patients.

Urethral sphincter
Covered for patients with urinary incontinence consequent to permanent and neurological dysfunctions of the bladder.

Urinary collection system (A4310-A4328, A4331- A4359, A5102-A5114, A5131)

Covered when ordered for permanent urinary incontinence. Included are male external catheters as part of a urinary collection and retention system that replaces the function of the bladder. Intermittent urinary catheters (A4351-A4353) and trays (A4310) are covered when ordered for permanent urinary incontinence (788.30-788.39), urinary obstruction (599.6),urinary retention (788.20-788.29), and neurogenic bladder (344.61, 596.54).

Payment for non-sterile or sterile catheters may be allowed when ordered by the treating physician as medically necessary for the individual patient's needs.

Supplies such as incontinence garments (e.g., brief, diaper)(A4520) and underpads (A4554) are not part of a urinary collection system, and are not prosthetic devices.

These items are considered durable medical equipment. See Incontinence Supplies on Medical Policy Bulletin E-1.

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.