43.4.9.5 Corrective Shoe, Wedge, and LiftTHSteps-CCP may authorize and reimburse prescription shoes (corrective/orthopedic), wedges, and lifts. The authorization request and reimbursement must meet the following requirements: Corrective Shoes For consideration of coverage, corrective shoes must be prescribed by a licensed physician (MD or DO) or a podiatrist and meet one of the following requirements:
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• Note: Corrective shoes that are not attached to a brace require authorization. Requests for corrective shoes that do not meet the criteria listed above may be submitted with the appropriate documentation to medical review for consideration. A corrective shoe does not include tennis shoes (even if prescribed by a physician and worn with a removable brace). A corrective shoe does not include a shoe insert when it is not part of a modified shoe or when the shoe in which it is inserted is not attached to a brace (other than procedure code 9-L3000). Only one pair of corrective shoes can be authorized every three months. Two pairs of shoes may be purchased at the same time; however, in such situations additional requests for shoes are not considered for another six months. Requests for corrective shoes that do not meet the criteria listed above may be submitted with the appropriate documentation to medical review for consideration. Authorization requests for corrective shoes must be submitted in writing. Wedge and Lift A wedge or lift must be for unequal leg length greater than one-half inch. Reimbursement may include the cost of the prescription shoe. Dynamic Splint Requests for dynamic splints may be submitted for medical review with the following documentation supporting medical necessity:
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• Removable Shoe Insert, UCB (University of California at Berkeley) Type Shoe inserts are not a benefit when they are not part of a modified shoe or when the shoe in which they are inserted is not attached to a brace, with the exception of the UCB removable shoe insert. A UCB removable shoe insert may be prior authorized and reimbursed when the service meets one of the following:
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• Procedure code 9-L3000 may be payable when billing for a removable foot insert. Reciprocating Gait Orthoses (RGO) RGO may be covered for clients with spina bifida or similar functional disabilities. Prior authorization is required. The prior authorization request must include a statement from the prescribing physician indicating the medical necessity, PT plan, and information that the family is expected to comply with the treatment plan. Note: Prior authorization is a condition for reimbursement, not a guarantee of payment. Repairs, Modifications, and Fittings of Orthosis/Prostheses Repairs due to regular wear and modifications due to growth or change in medical status are a benefit when proven more cost-effective than replacing the device. Additional information from the provider may be requested to determine cost-effectiveness. Authorization is required for repairs, modifications, and fittings. Documentation supporting medical necessity must be provided when requesting authorization. Reimbursement of fittings is considered included in the regular reimbursement fee except in situations such as parapodiums, where time spent at fitting may be extensive. Fitting for parapodiums must be prior authorized. For repairs, modifications, and fittings to an orthosis, providers must bill using procedure codes 9-E1340, 9-L4205, and 9-L4210. Replacement of Orthoses/Prostheses Replacement of an orthotic/prosthetic device is considered when loss or irreparable damage has occurred. A copy of the police or fire report is required when appropriate, along with the measures to be taken to prevent recurrence of similar loss. Supporting medical documentation is required for the replacement of an orthotic or prosthetic device if less than six months from the actual date the client received the device. If less than one year since initial purchase, request for replacement is referred to the medical director for review. In situations where the equipment has been abused or neglected by the client, the client's family or the caregiver, a referral to the DSHS THSteps Case Management unit is made by the Home Health Services unit for clients birth to 20 years of age. Providers are notified that the State is monitoring this client's services to evaluate the safety of the environment for both the client and equipment. Training in Using the Orthotic or Prosthetic Device Training in the use of an orthotic or prosthetic device for a client who has not worn one previously, has not worn one for a prolonged period, or is receiving a different type may be reimbursed when the training is provided by a PT or OT. If prior authorization is not requested, submit documentation to support medical necessity with each claim and include a prescription signed by a physician (MD or DO). A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. Prior authorization is a condition for reimbursement, not a guarantee of payment. Physician Signature The physician's signature and date is required on a prescription and the THSteps-CCP Prior Authorization Request Form must be current to the service date of the request. Refer to: "Physician Signature" for complete information about this requirement. |
Permanently attached to a brace.
