CSHCN 2009 > Orthotic and Prosthetic Devices > Benefits, Limitations, and Authorization Requirements

26.2.1 General Authorization Requirements

Requests for authorization must be in writing on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)form with all procedure codes included. A copy of this form is provided in Appendix B, "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)". Modifications of orthotic and prosthetic systems, due to growth or a change in medical status, may be authorized. Repairs required due to normal wear may be authorized. Additional information may be requested to determine if repairs and modifications are cost-effective.

Authorization with medical justification is required for replacement of orthoses, if less than 6 months from the receipt of the initial system, and for prostheses, if less than 1 year from receipt of the initial permanent system.

Preparatory or temporary prostheses may be replaced in less than 12 months of receipt, but should go to medical review if the permanent prosthesis is requested less than 6 months after provision of the preparatory or temporary prosthesis.

Replacement of an orthotic or prosthetic device is considered when loss or irreparable damage has occurred due to a traumatic event (e.g., vehicle accident, a residential fire, theft, etc.). A copy of the police or fire report is required, when appropriate, along with the measures to be taken to prevent a repeat of similar loss.