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2.7.2.2.5 Other Orthopedic Devices
Protective Helmets
Protective helmets will be considered for prior authorization for clients with a documented medical condition that makes the client susceptible to injury during ADLs. Covered medical conditions include the following:
• Neoplasm of the brain
•Subarachnoid hemorrhage
•Epilepsy
•Cerebral palsy
Requests for all conditions other than those listed above require submission of additional documentation that supports the medical necessity of the requested device.
Dynamic Splints
Dynamic splints such as Dynasplint®will be considered for prior authorization for a three-month trial period when the request is submitted with the following documentation:
•Client's condition
•Client's current course of therapy
•Rationale for the use of the dynamic splint
•Agreement by the client or family that the client will comply with the prescribed use of the dynamic splint
After completion of the three-month trial period, the provider may submit a request for purchase of the dynamic splint. Requests for purchase of the splint must include documentation that the three-month trial period was successful and showed improvement in the client's condition as measured by the following:
•Demonstrated increase in range of motion
•Demonstrated improvement in the ability to complete ADL's or perform activities outside the home
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