Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-9
Topic: Screening List For Prosthetics and Orthotics
Effective Date: January 1, 2010
Issued Date: September 27, 2010
Date Last Reviewed:

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.

An orthotic device or orthosis (commonly known as a brace or splint) is an orthopedic device that is applied externally to the limb or body.  The purpose can be to provide support, protection or replacement of lost function.  There are a large variety of devices available depending on the diagnosis and physical needs of the individual.  Orthoses are named for the body segment or area that they cover or the particular function they provide.

Claims for prosthetic/orthotic 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

A4310A4311A4312A4313A4314A4315
A4316 A4320 A4321A4322A4326A4327
A4328 A4331A4332A4333A4334A4335
A4336A4338A4340A4344 A4346A4349
A4351A4352A4353A4354A4355A4356
A4357A4358A4360A4361A4362A4363
A4366A4367A4368A4369A4371A4372
A4373A4375A4376A4377A4378A4379
A4380A4381A4382A4383A4384A4385
A4387A4388A4389A4390A4391A4392
A4393A4394A4395A4396A4397A4398
A4399A4400A4402A4404A4405A4406
A4407A4408A4409A4410A4411A4412
A4413A4414A4415A4416A4417A4418
A4419A4420A4421A4422A4423A4424
A4425A4426A4427A4428A4429A4430
A4431A4432A4433A4434A4456A4481
A4483A4520A4554A4605A4623A4624
A4625A4626A4629A5051A5052A5053
A5054A5055A5061A5062A5063A5071
A5072A5073A5081A5082A5083A5093
A5102A5105A5112A5113A5114A5120
A5121A5122A5126A5131A5200A7501
A7502A7503A7504A7505A7506A7507
A7508A7509A7520A7521A7522A7523
A7524A7525A7526A7527D5110D5120
D5130D5140D5225D5226E1399E0740
L3999L8609S8189   

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
  • Hearing aids for children up to age 22, limited to $1,000 per ear per calendar year
  • Bone anchored hearing aids (BAHA'S) when medically necessary for members with traumatic injury or malformation of the external ear or middle ear (such as a surgically induced malformation or congenital malformation), limited to $1,000 per ear per calendar year.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

LCD L11502

CMS Transmittal #39, CR 4038

National Coverage Determination 50.2, Electronic Speech Aids

National Coverage Determination 50.4, Trachea Supplies

National Coverage Determination 160.19, Phrenic Nerve Stimulator

National Coverage Determination 230.8, Non-implantable Pelvic Floor Electrical Stimulator

National Coverage Determination 230.10, Mechanical/hydraulic Incontinence Aids

National Coverage Determination 230.15, Electrical Continence Aid

National Coverage Determination 230.16, Bladder Stimulators

National Coverage Determination 230.17, Urinary Collection System

Farrell JF, Hoffman HB, Snyder JL, Giuliani CA, Bohannon RW. Orthotic Aided Training of the Paretic Upper Limb in Chronic Stroke:  Results of a Phase 1 Trial. Saebo, Inc., Charlotte, NC, NeuroRehabilitation,. 2007;22(2):99-103.

Barry JG, Saabye S, Baker D, Fogarty J, Beck K. Effects of the SaeboFlex Orthosis and a Home Exercise Program on Upper Extremity Recovery in Individuals with Chronic Hemiparesis. Journal of Neurologic Physical Therapy.  December 2006;Volume 30(4) p 207.

Journal of Rehabilitation Medicine, Stroke Rehab. Gothenburg, Sweden. April 2006;26-28  

NeuroRehabilitation. Number 2/2007;Volume 22

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Table Attachment

Screening List for Prosthetic/Orthotic Devices
Item Coverage Status
Artificial cornea (L8609)
DLR - 10/2008

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 - 09/2010		 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.

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, A4366-A4434, A4456, 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 (A4369, A4371, A4405, A4406, A4456, A5120) 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.
SaeboFlex (L3999)
DLR 6/2010

Deny-experimental/investigational.  Scientific evidence does not demonstrate the effectiveness of this device.

 
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-A4360, 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 , urinary obstruction, urinary retention, and neurogenic bladder.

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 Attachments

Diagnosis Codes

For procedure code E0740:

625.6788.31788.33 

For procedure codes A4310 and A4351-A4353:

344.61596.54599.60599.69
788.20-788.29788.30-788.39  

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.