Medical_Policy

Mountain State Medical Policy Bulletin

Section:	Orthotic & Prosthetic Devices
Number:	O-9
Topic:	Screening List For Prosthetic Devices
Effective Date:	January 1, 2007
Issued Date:	January 1, 2007
Date Last Reviewed:	12/2006

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.

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

A4310	A4311	A4312	A4313	A4314	A4315
A4316	A4320	A4321	A4322	A4326	A4327
A4328	A4331	A4332	A4333	A4334	A4335
A4338	A4340	A4344	A4346	A4349	A4351
A4352	A4353	A4354	A4355	A4356	A4357
A4358	A4361	A4362	A4363	A4365	A4366
A4367	A4368	A4369	A4371	A4372	A4373
A4375	A4376	A4377	A4378	A4379	A4380
A4381	A4382	A4383	A4384	A4385	A4387
A4388	A4389	A4390	A4391	A4392	A4393
A4394	A4395	A4396	A4397	A4398	A4399
A4400	A4402	A4404	A4405	A4406	A4407
A4408	A4409	A4410	A4411	A4412	A4413
A4414	A4415	A4416	A4417	A4418	A4419
A4420	A4421	A4422	A4423	A4424	A4425
A4426	A4427	A4428	A4429	A4430	A4431
A4432	A4433	A4434	A4481	A4483	A4520
A4554	A4605	A4623	A4624	A4625	A4626
A4629	A5051	A5052	A5053	A5054	A5055
A5061	A5062	A5063	A5071	A5072	A5073
A5081	A5082	A5093	A5102	A5105	A5112
A5113	A5114	A5120	A5121	A5122	A5126
A5131	A5200	A7501	A7502	A7503	A7504
A7505	A7506	A7507	A7508	A7509	A7520
A7521	A7522	A7523	A7524	A7525	A7526
A7527	D5110	D5120	D5130	D5140	D5225
D5226	E1399	E0740	L8609	S8189

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

FEP covers prosthetic appliances such as:

Artificial limbs and eyes
Functional foot orthotics when prescribed by a physician
Rigid devices attached to the foot or a brace, or placed in a shoe
Replacement, repair, and adjustment of covered devices
Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
Surgically implanted penile prostheses to treat erectile dysfunction

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

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[Version 002 of O-9]

[Version 001 of O-9]

Table Attachment

Screening List for Prosthetic Devices

Item	Coverage Status
Artificial cornea (L8609) DLR - 10/2006	Deny-experimental/investigational. Scientific evidence does not demonstrate the safety and effectiveness of this device.
Catheters and Cunningham clamps	See urinary collection system.
Dentures (D5110-D5140, D5225, D5226)	Excluded from coverage.
Electrical continence aids DLR - 09/2006	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-A4363, A4365-A4434, A5051-A5093, A5120-A5131, A5200)	Covered for ostomy patients. NOTE: Payment may be made for skin barrier codes A4362, A4372, A4373, A4385, A4407-A4411, 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, A5120) used for diabetics, see Medical Policy Bulletin B-46.
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- A4346, A4349-A4358, 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 (599.60, 599.69), 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.