Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.7 Orthotic and Prosthetic Services (CCP) : 2.7.5 Prosthetic Services : 2.7.5.2 Prior Authorization and Documentation Requirements

2.7.5.2
Prior authorization is required for all prosthetic devices.
A completed CCP Prior Authorization Form requesting the prosthesis must be signed and dated by a physician familiar with the client before requesting prior authorization for all prostheses. All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures/dates will not be accepted. The completed CCP Prior Authorization Form must include the procedure codes and numerical quantities for services requested. A copy of the completed, signed, and dated form must be maintained by the prosthesis provider in the client's medical record. The completed CCP Prior Authorization Form with the original dated signature must be maintained by the prescribing physician in the client’s medical record.
To complete the prior authorization process by paper, the prosthesis provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP prior authorization unit and retain a copy of the signed and dated CCP form in the client’s medical record at the provider’s place of business.
To complete the prior authorization process electronically, the prosthesis provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CCP Prior Authorization Request form in the client’s medical record at the provider’s place of business.
To facilitate determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the equipment or supplies requested. The physician must maintain documentation of medical necessity in the client’s medical record. The provider may be asked for additional information to clarify or complete a request for the service or device.
All requests for prior authorization must include documentation of medical necessity including, but not limited to, documentation that the client meets the following general indications for the requested device:
The prosthesis replaces all or part of the function of a permanently inoperative, absent, or malfunctioning part of the limb, and identification of the specific limb that is being replaced by the prosthesis.
The provider must keep the following written documentation in the client’s medical record:
The prescription must be dated prior to or on the initial date of the requested dates of service, which can be no longer than 90 days from the signature date on the prescription.
Accurate diagnostic information that supports the medical necessity for the requested device. (A retrospective review may be performed to ensure that the documentation included in the client’s medical record supports the medical necessity of the requested service or device.)
Prior authorization is valid for a maximum period of six months from the prescription signature date. At the end of the six-month authorization period, a new prescription is required for prior authorization of additional services.
The actual date of service is the date the supplier has placed an order for the equipment and has incurred liability for the equipment.
2.7.5.2.1 Lower-Limb Prostheses
Lower limb prostheses include, but are not limited to, the following:
A basic lower limb prosthesis consists of the following:
In addition to the general indication requirements, the following additional documentation is also required for all lower limb prostheses:
Written documentation of the client’s current and potential functional levels. A functional level is defined as a measurement of the capacity and potential of the individuals to accomplish their expected post-rehabilitation daily function. The potential functional ability is based on reasonable expectations of the treating physician and the prosthetist and includes, but is not limited to, the following:
The following functional classification levels have been defined by the Centers for Medicare & Medicaid Services (CMS):
Does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility.
Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator
Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.
Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.
A client whose functional level is zero (0) is not a candidate for a prosthetic device; the device is not considered medically necessary.
Microprocessor-Controlled Lower Limb Prostheses
Microprocessor-controlled lower limb prostheses (e.g., Otto Bock C-Leg, Intelligent Prosthesis, or Ossur Rheo Knee) will be considered for prior authorization for clients who have a transfemoral amputation from a nonvascular cause, such as trauma or tumor and a functional level of 3 or above, and who meet the following criteria:
The individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level of technology and to allow for faster than normal walking speed.
The individual has a demonstrated need for long-distance ambulation at variable rates (greater than 400 yards) on a daily basis. Use of the limb in the home or for basic community ambulation is not sufficient to justify provision of the computerized limb instead of standard limb applications.
The individual has a demonstrated need for regular ambulation on uneven terrain or for regular use on stairs. Use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application.
The licensed prosthetist or licensed prosthetist/orthotist providing the device must be trained in the fitting and programming of the microprocessor-controlled prosthetic device.
Foot Prostheses
The following foot prostheses will be considered for prior authorization for clients whose documented functional level is 1 or above:
A flexible-keel foot or multi-axial ankle/foot will be considered for prior authorization for clients whose documented functional level is 2 or above.
A flex foot system, energy storing foot, multiaxial ankle/foot, dynamic response, or flex-walk system or equivalent will be considered for prior authorization for clients whose documented functional level is 3 or above.
A prosthetic shoe will be considered for prior authorization if it is an integral part of a prosthesis for clients with a partial foot amputation.
Ankle Prosthesis
An axial rotation unit will be considered for prior authorization for clients whose documented functional level is 2 or above.
Knee Prosthesis
A single-axis, constant-friction knee and other basic knee systems will be considered for prior authorization for clients whose documented functional level is 1 or above. A fluid, pneumatic, or electronic knee prosthesis will be considered for prior authorization for clients whose documented functional level is 3 or above. A high-activity knee control frame will be considered for prior authorization for clients whose documented functional level is 4.
Prosthetic Substitutions or Additions for Below-Knee Prostheses
Prosthetic substitutions or additions (procedure codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980) are not considered medically necessary when an initial below-knee prosthesis (procedure code L5500) or a preparatory below-knee prosthesis (procedure codes L5510, L5520, L5530, or L5540) is provided.
Prosthetic substitutions or additions (procedure codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962) are not considered medically necessary when a below-knee preparatory, prefabricated prosthesis (procedure code L5535) is provided.
Prosthetic Substitutions or Additions for Above-Knee Prostheses
Prosthetic substitutions or additions (procedure codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710, L5780, L5790, and L5795) are not considered medically necessary when an above-knee initial prosthesis (procedure code L5505) or an above-knee preparatory prosthesis (procedure codes L5560, L5570, L5580, L5590, L5595, or L5600) is provided.
Prosthetic substitution or additions (procedure codes L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966) are not considered medically necessary when an above-knee preparatory, prefabricated prosthesis (procedure code L5585) is provided.
Sockets
Prior authorization for test (diagnostic) sockets for an individual prosthesis is limited to a quantity of two test sockets. Prior authorization for same-socket inserts for an individual prosthesis is also limited to a quantity of two. Requests for test sockets or same-socket inserts beyond these limitations must include documentation of medical necessity that supports the need for the additional sockets.
2.7.5.2.2 Upper-Limb Prostheses
Upper limb prostheses include, but are not limited to, the following:
Upper limb prostheses will be considered for prior authorization with documentation of all of the general indication requirements. The additional criteria in the following sections apply for specific prosthetic devices.
Myoelectric Upper Limb Prostheses
A myoelectric upper limb prosthetic device is considered medically necessary when all of the following criteria have been met:
The client does not function in an environment that would inhibit function of the prosthesis (e.g., a wet environment or a situation involving electrical discharges that would affect the prosthesis).
2.7.5.2.3 External Breast Prostheses
External breast prostheses will be considered for prior authorization for clients who have congenital absence of a breast or who have had a mastectomy.
2.7.5.2.4 Craniofacial Prostheses
Craniofacial prostheses include, but are not limited to, external nasal, ear, and facial prostheses.
Craniofacial prostheses will be considered for prior authorization with documentation that the device is necessary to correct an absence or deformity of the affected body part.
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:
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:
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.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.