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2.7.5.2.5 Related Services
Accessories to Prostheses
Accessories to prostheses, such as stump stockings and harnesses will be considered for prior authorization when they are essential to the effective use of the prosthetic device.
Repairs, Replacements and Modifications to Prostheses
Repairs due to normal wear and tear will be considered for prior authorization after 90 days from the date of delivery of the initial prosthesis, when the repair is:
• Necessary to make the equipment functional.
•More cost-effective than the replacement of the prosthetic device.
Providers must include documentation that supports medical necessity when they request prior authorization. Additional information from the provider may be requested to determine cost-effectiveness.
Replacement of prosthetic equipment will be considered for coverage when loss or irreparable damage has occurred. A copy of the police or fire report when appropriate and the measures to be taken to prevent reoccurrence must be submitted with the prior authorization request.
Socket replacements will be considered for prior authorization with documentation of functional or physiological need, including, but not limited to, changes in the residual limb, functional need changes, or irreparable damage or wear due to excessive weight or prosthetic demands of very active amputees.
Children typically require new prosthetic devices every 12 to 18 months, although the actual lifespan of a device depends on the child's rate of skeletal growth. Prosthetic devices for children must accommodate growth and other physiological changes.
Components and systems that allow for growth or increase the lifespan of the prosthesis may include the following:
•Growth-oriented suspension systems and modifications
•Use of modular systems
•Use of flexible sockets
•Use of removable sockets (slip or triple-wall sockets)
•Use of distal pads
•Modification of socket liners
•Increasing or decreasing sock thickness
Modifications due to growth or change in medical status will be considered for prior authorization with documentation of medical necessity.
Medical necessity for requested components or additions to the prosthesis is based on the client's current functional ability and the expected functional potential as defined by the prosthetist and the ordering physician.
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