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43.4.5.6 Thoracic-Hip-Knee-Ankle Orthoses (THKAO) (Vertical or Dynamic Standers, Standing Frames/Braces, and Parapodiums)
THKAO (vertical or dynamic standers, standing frames or braces, and parapodiums), including all accessories, require prior authorization. A THKAO may be considered if the client requires assistance to stand and remain standing. A THKAO is not considered for prior authorization if the client already owns a stander (other than a vertical stander or standing frame or brace) or gait trainer.
Prior authorization may be considered for the THKAOs with the following documentation:
• Diagnoses relevant to the requested equipment, including functioning level and ambulatory status.
•Anticipated benefits of the equipment.
•Frequency and amount of time of a standing program.
•Anticipated length of time the client will require this equipment.
•Clients height/weight/age.
•Anticipated changes in the client's needs, anticipated modifications, or accessory needs, as well as the growth potential of the stander.
Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.
Vertical or Dynamic Stander
A vertical stander or dynamic stander is used to initiate standing for clients who cannot maintain a good standing posture or may never be able to stand independently. A vertical stander is used to develop weight bearing through the legs in order to decrease demineralization and to promote better body awareness. Documentation for these standers must address medical necessity for the standers to be mobile.
Providers must use procedure code 9-L1510 for a vertical stander. Providers must use procedure code J-E0642 for a dynamic stander.
Standing Frame or Brace
A standing frame or brace is used to help very young clients, 12 months of age or older, who have good head control in the upright position and who have a neuromuscular disease/condition resulting in a lack of sufficient muscle power in the trunk and lower extremities to stand with their hands free.
Providers must use procedure code 9-L1510 for a standing frame or brace.
Parapodium
A parapodium is used to help clients with neuromuscular diseases/conditions resulting in a lack of sufficient muscle power in the trunk and lower extremities to stand with their hands free. It helps develop a sense of balance and aids in learning functional movements such as standing with the hands free. A parapodium acts as an exoskeleton, providing side struts and chest, hip, knee, and foot bracing.
A parapodium may be considered for reimbursement for one of the following levels:
•Level One: Small Parapodium. The client has a maximum axillary height of 35 inches and a maximum weight of 55 pounds (normal age range is 1 through 10 years of age). Providers must use procedure code 9-L1500 or 9-L1520.
•Level Two: Medium parapodium. The client has a maximum axillary height of 41 inches and a maximum weight of 77 pounds (normal age range is 5 through 12 years of age). Providers must use procedure code 9-L1500-TF or 9-L1520-TF.
•Level Three: Large parapodium. The client has a maximum axillary height of 45 inches and a maximum weight of 115 pounds (normal age range is 10 through 16 years of age). Providers must use procedure code 9-L1500-TG or 9-L1520-TG. Labor for parapodium assembly may be prior authorized.
Feeder Seats, Floor Sitters, Corner Chairs, and Travel Chairs
Feeder seats, floor sitters, corner chairs, and travel chairs are not considered medically necessary and are not a benefit of THSteps-CCP. If a client requires seating support and meets the criteria for a seating system, a stroller may be considered for reimbursement with prior authorization through THSteps-CCP, or a wheelchair may be considered through Texas Medicaid (Title XIX) Home Health Services.
Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.
Scooters
Scooters may be considered for reimbursement through Texas Medicaid (Title XIX) Home Health Services.
Equipment Accessories
THSteps-CCP may consider prior authorization of equipment accessories, such as ventilator and oxygen trays and positioning inserts, when supporting documentation takes into account all the client's needs, capabilities, and physical/mental status.
Note: Prior authorization is a condition for reimbursement, not a guarantee of payment.
Equipment Modifications
A modification is the replacement of a component due to changes in the client's condition, not the replacement of a component that is no longer functioning.
All modifications within the first six months after delivery are considered part of the purchase price.
THSteps-CCP may consider prior authorization of modifications to custom equipment if a change occurs in the client's needs, capabilities, or physical/mental status that cannot be anticipated. Documentation must include:
•All projected changes in the client's needs.
•The age of the current equipment, and the cost of purchasing new equipment versus modifying current equipment.
Equipment Adjustments
Adjustments do not require supplies.
Adjustments within the first six months after delivery are not prior authorized, because these are considered part of the purchase price.
Up to one hour of labor for adjustments may be considered for reimbursement with prior authorization through THSteps-CCP as needed after the first six months. Providers must use procedure code 9-E1340 for adjustments.
Equipment Repairs
Repairs require replacement of components that are no longer functional. Repairs to client-owned equipment may be considered for reimbursement with prior authorization through THSteps-CCP.
Technician fees are considered part of the cost of the repair. Providers must use procedure code 9-E1340.
Providers are responsible for maintaining documentation in the client's medical record specifying the repairs and supporting medical necessity.
A request for authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply.
Rentals may be considered for reimbursement during the repair period of the client's owned equipment.
Routine maintenance of rental equipment is the provider's responsibility.
Mobility Aids - THSteps-CCP HCPCS Procedure Codes and Limitations
Providers must use modifiers TF and TG for equipment repairs.
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