Orthotic and Prosthetic Devices

28.1​Enrollment

To enroll in the CSHCN Services Program, an orthotics and prosthetics provider must be actively enrolled in Texas Medicaid as a durable medical equipment (DME) provider or as a licensed prosthetist and/or orthotist, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process by enrolling as an individual or as a group of performing providers, and comply with all applicable state laws and requirements. The CSHCN Services Program does not enroll orthotists and prosthetists as facilities. Out-of-state orthotics and prosthetics providers must meet all of these conditions, and be located in the United States, within 50 miles of the Texas state border, and approved by the Department of State Health Services (DSHS).

​Important:CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid.

By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 26 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371.

CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1659 for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 26 TAC §351.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his/her profession, as well as those required by the CSHCN Services Program and Texas Medicaid.

​Refer to: Section 2.1, “Provider Enrollment” in Chapter 2, “Provider Enrollment and Responsibilities” for more detailed information about CSHCN Services Program provider enrollment procedures.

28.2​Benefits, Limitations, and Authorization Requirements

Orthoses, prostheses, and prescription shoes may be a benefit of the CSHCN Services Program. These benefits are solely for external orthoses and prostheses. Items must be prescribed by a licensed physician or podiatrist (for conditions below the ankle) and fitted by an orthotist or prosthetist enrolled in the CSHCN Services Program, even if the device is supplied by another enrolled provider type. Noncustom commercial products may be supplied through a physician’s office. Licensed occupational therapists may provide upper extremity splints and inhibitive casting, and licensed physical therapists may provide lower extremity inhibitive casts.

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 time period, or is receiving a different type may be reimbursed when provided by a licensed PT or OT. Therapy for the purpose of training a client in the use of an orthotic or prosthetic device will be approved for up to five times a week for 1 month; then three times a week for 2 months. Additional request forms require documentation of medical necessity.

28.2.1​General Authorization Requirements

All orthoses and prostheses procedures addressed in this chapter require prior authorization. Requests for prior authorization must be in writing on a completed CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form with all procedure codes included. Documentation that supports the medical necessity of the requested item must be included with the prior authorization request.

Modifications of orthotic and prosthetic systems, due to growth or a change in medical status, may be prior authorized. Repairs required due to normal wear may be prior authorized. Additional information may be requested to determine if repairs and modifications are cost-effective.

28.2.2​Orthoses and Prostheses (Not All-Inclusive)

The following listed conditions are a guide. Additional documentation of medical necessity must be provided if orthoses, prostheses (artificial limbs), or other orthopedic devices are requested for an unlisted condition:

28.2.2.1​Repairs, Replacements, and Modifications to Orthoses and Prostheses

Repairs, replacements, and modifications to orthoses and prostheses are a benefit of the CSHCN Services Program when medically necessary criteria are met.

Repairs due to normal wear and modifications due to growth or change in medical status will be considered for prior authorization when the repair or modification is more cost-effective than the replacement of the device.

•​Additional information from the provider may be requested to determine cost-effectiveness.

•​Documentation supporting medical necessity must be provided when requesting prior authorization.

Replacement of orthotic or prosthetic devices will be considered for prior authorization with medical justification.

•​Orthotic devices are anticipated to last a minimum of 6 months from the receipt of the initial system.

•​Prosthetic devices are anticipated to last a minimum of one year from the receipt of the initial definitive/permanent system.

•​Preparatory or temporary prostheses may be replaced in less than 12 months of their receipt, but they will undergo medical review if the permanent prosthesis is requested less than 6 months after provision of the preparatory or temporary prosthesis.

•​Replacement of an orthosis or prosthesis will be considered when loss or irreparable damage has occurred due to a traumatic event such as a vehicle accident, a residential fire, or theft. A copy of the police or fire report is required when appropriate, along with the measures to be taken to prevent a repeat of similar loss.

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.

28.2.2.2​Mechanical Stretching Devices

Mechanical stretching devices are a benefit of the CSHCN Services Program. Mechanical stretching devices are not motorized and may be prefabricated or custom fabricated. The following are Classifications of Stretching Devices:

•​Dynamic low-load prolonged-duration stretch (LLPS) devices

•​Static progressive stretch (SPS) device

•​Patient-actuated serial stretch (PASS) device

28.2.2.3​Orthoses and Prostheses Training

Training in the use of an orthosis or prosthesis for a client who has not worn one previously, has not worn one for a prolonged time period, or is receiving a different type is a benefit when the training is provided by a licensed physical or occupational therapist.

Therapy for the purpose of training a client in the use of an orthosis or prosthesis may be approved for up to 5 times per week for 1 month; then 3 times per week for 2 months. Additional requests will require medical review.

RGO and dynamic splints require medical review at the onset of training therapy.

28.3​Orthoses and Related Services

All requests for prior authorization must include documentation of medical necessity including documentation that the client meets one of the following general indications for the requested device:

•​Reducing pain by restricting mobility of the affected body part

•​Facilitating healing following injury or surgery to the affected body part

•​Supporting weak muscles or a deformity of the affected body part

The provider must maintain written documentation in the client’s medical record including the prescription for the device and accurate diagnostic information supporting the medical necessity for the requested device.

28.3.1​Prior Authorization and Documentation Requirements

Prior authorization is required for all orthoses and related services. All requests for prior authorization must include documentation of medical necessity including, but not limited to, documentation that the client meets all of the following general indications for the requested device.

Orthoses will be considered for prior authorization with documentation that the device is needed for one of the following indications:

•​To reduce pain by restricting mobility of the affected body part.

•​To facilitate healing following an injury to the affected body part or related soft tissue.

•​To facilitate healing following a surgical procedure on the affected body part or related soft tissue.

•​To support weak muscles and/or a deformity of the affected body part.

The provider must maintain the following written documentation in the client’s medical record:

•​The prescription for the device.

•​Orthotic and devices must be prescribed by a physician (M.D., D.O.) or a podiatrist. A podiatrist prescription is valid for conditions of the ankle and foot.

•​Accurate diagnostic information supporting the medical necessity for the requested device.

•​The 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.

•​Other orthopedic devices will be considered for prior authorization with documentation of medical necessity as outlined for the specific orthotic device.

28.3.2​Orthotic and Orthopedic Devices Procedure Codes

The following orthoses procedure codes may be reimbursed in the home setting to an orthotist, prosthetist, medical supplier (DME), and custom DME provider:

28.3.3​Noncovered Orthotic and Prosthetic Services

The following services are not a benefit of the CSHCN Services Program:

•​Replacement or repair of an orthotic or prosthetic device due to confirmed misuse or abuse by the client, the client’s family, or the vendor

•​Orthoses primarily used for athletic or recreational purposes

28.3.4​Spinal Orthoses

Spinal orthoses include, but are not limited to, cervical orthoses, thoracic rib belts, thoracic-lumbar-sacral orthoses (TLSO), sacroiliac orthoses, lumbar orthoses, lumbar-sacral orthoses (LSO), cervical- thoracic-lumbar-sacral orthoses (CTLSO), halo procedures, spinal corset orthoses, and spinal orthoses for scoliosis.

Spinal orthoses will be considered for prior authorization with documentation of one of the general indications in Section 28.3.1, “Prior Authorization and Documentation Requirements” in this chapter.

28.3.5​Thoracic-Hip-Knee-Ankle (THKA) Orthoses

THKA orthoses will be considered for prior authorization with documentation of one of the general indications outlined in Section 28.3.1, “Prior Authorization and Documentation Requirements” in this chapter.

28.3.6​Lower-Limb Orthoses

Lower-limb orthoses include, but are not limited to, hip orthoses (HO), Legg Perthes orthoses, knee orthoses (KO), ankle-foot orthoses (AFO), knee-ankle-foot orthoses (KAFO), hip-knee-ankle-foot orthoses (HKAFO), fracture orthoses, and reciprocating gait orthoses (RGO).

In addition to the general indication requirements, lower-limb orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices.

28.3.6.1​Ankle-Foot Orthoses (AFO)

AFOs used during ambulation will be considered for prior authorization for clients with documentation of all of the following:

•​Weakness or deformity of the foot and ankle

•​A need for stabilization for medical reasons

•​Anticipated improvement in functioning during activities of daily living (ADLs) with use of the device

AFOs not used during ambulation (static AFO) will be considered for prior authorization for clients with documentation of one of the following conditions:

•​Plantar fasciitis

•​Plantar flexion contracture of the ankle, with additional documentation that includes all of the following:

•​Dorsiflexion on pretreatment passive range of motion testing is at least ten degrees.

•​The contracture is interfering or is expected to interfere significantly with the client’s functioning during ADLs.

•​The AFO will be used as a component of a physician-prescribed therapy plan care, which includes active stretching of the involved muscles or tendons.

•​There is reasonable expectation that the AFO will correct the contracture.

28.3.6.2​Reciprocating Gait Orthoses (RGO)

Reciprocating gait orthoses will be considered for prior authorization for clients with spina bifida or similar functional disabilities.

The prior authorization request must include a statement from the prescribing physician that indicates medical necessity for the RGO, the physical therapy treatment plan, and documentation that the client or family is willing to comply with the treatment plan.

28.3.7​Foot Orthoses

Foot orthoses include, but are not limited to, foot inserts, orthopedic shoes, wedges, and lifts.

Foot orthoses will be considered for prior authorization for clients with documentation of all the following:

•​The client has symptoms associated with the particular foot condition.

•​The client has failed to respond to a course of appropriate, conservative treatment, including physical therapy, injections, strapping, or anti-inflammatory medications.

•​The client has at least one of the following:

•​Torsional conditions, such as metatarsus adductus, tibial torsion, or femoral torsion

•​Structural deformities

•​Hallux valgus deformities

•​In-toe or out-toe gait

•​Musculoskeletal weakness

In addition to the general indication requirements, foot orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices.

28.3.7.1​Foot Inserts

Removable foot inserts will be considered for prior authorization for clients with documentation of at least one of the following medical conditions:

•​Diabetes mellitus

•​History of amputation of the opposite foot or part of either foot

•​History of foot ulceration or pre-ulcerative calluses of either foot

•​Peripheral neuropathy with evidence of callus formation of either foot

•​Deformity of either foot

•​Poor circulation of either foot

The CSHCN Services Program may authorize removable foot inserts independently of orthopedic shoes with documentation that the client has appropriate footwear into which the insert can be placed.

A University of California–Berkeley (UCB) removable foot insert will be considered for prior authorization with documentation that the device is required to correct or treat at least one of the following conditions:

•​A valgus deformity and significant congenital pes planus, which is symptomatic for pain

•​A structural problem which results in significant pes planus

•​Acute plantar fasciitis

•​A diagnosis of hemophilia

Authorization requests for removable shoe insert must be submitted on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form.

​Refer to: Section 4.3, “Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about authorization requirements.

28.3.7.2​Prescription Shoes

Prescription shoes (corrective or orthopedic shoes) must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist. An orthopedic shoe is used by clients whose feet, although impaired, are essentially intact. An orthopedic shoe differs from a prosthetic shoe, which is used by clients who are missing all or most of the forefoot.

Orthopedic shoes will be considered for prior authorization when at least one of the following criteria is met:

•​The shoe is permanently attached to a brace.

•​The shoe is custom modified by an orthotist or prosthetist/orthotist at the direction of the prescribing physician.

•​The shoe is necessary to hold a surgical correction, postoperative casting, or serial or clubfoot.

•​Casting (does not have to be attached to a brace). A prescription shoe may be prior authorized up to one year from the date of the surgical procedure.

•​Documented by a physician as to specific medical rationale. Lifts for unequal leg length greater than one-half inch will be covered with documentation of medical need; the prescription shoe itself and the lift may be reimbursable.

Only one pair of prescription shoes will be prior authorized every three months. Two pairs of shoes may be purchased at the same time; in such situations, however, additional requests for shoes will not be considered for coverage for another six months.

If the primary diagnosis is valgus deformities of the feet, medical justification is required.

28.3.7.3​Noncovered Shoes or Shoe Inserts

The following are not considered a prescription shoe:

•​A tennis shoe, even if prescribed by a physician and worn with a removable brace.

•​A shoe insert when it is not a part of a modified shoe or when the shoe in which it is inserted is not attached to a brace (other than University of California–Berkeley-type, Healthcare Common Procedure Coding System [HCPCS] procedure code L3000).

28.3.7.4​Wedges and Lifts

Wedges and lifts must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist and must be for treatment of unequal leg length greater than one-half inch.

Prior authorization is required with justification of medical necessity for wedges and lifts.

28.3.8​Upper-Limb Orthoses

Upper-limb orthoses include, but are not limited to, shoulder orthoses (SO), elbow orthoses (EO), elbow-wrist-hand orthoses (EWHO), elbow-wrist-hand-finger orthoses (EWHFO), wrist-hand-finger orthoses (WHFO), wrist-hand orthoses (WHO), hand-finger orthoses (HFO), finger orthoses (FO), shoulder-elbow-wrist-hand orthoses (SEWHO), shoulder-elbow orthoses (SEO), and fracture orthoses.

In addition to the general indication requirements, upper-limb orthoses will be considered for prior authorization with documentation of one of the general indications outlined in Section 28.3.1, “Prior Authorization and Documentation Requirements” in this chapter.

28.3.9​Other Orthopedic Devices

28.3.9.1​Protective Helmets

Protective helmets used for conditions such as neoplasm of the brain, subarachnoid subdural hemorrhage, epilepsy, or cerebral palsy may be reimbursed by the CSHCN Services Program with prior authorization using the following procedure codes:

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.

28.3.9.2​Cranial Molding Orthosis

The CSHCN Services Program may cover cranial molding orthosis (procedure code S1040) for positional plagiocephaly with documentation supporting the use of the cranial molding orthosis to modify or prevent an associated functional impairment. Cranial molding orthosis may only be approved for children who are 3 through 18 months of age.

The CSHCN Services Program may cover cranial molding orthosis for use after surgery for cranial deformities, including craniosynostosis.

Studies indicate repositioning and physical therapy can be effective treatment for positional plagiocephaly. If detected early, repositioning combined with prone positioning while awake can correct the condition in the majority of children. For infants with a diagnosis of positional plagiocephaly who do not meet the criteria described in this chapter, the use of a cranial molding orthosis is considered cosmetic and, therefore, not medically necessary.

The effective use of cranial molding orthosis for the treatment of brachycephaly or a high cephalic index without cranial asymmetry has not been clearly documented, is not medically necessary, and, therefore, is not a benefit of the CSHCN Services Program.

28.3.9.2.1​Definitions of Plagiocephaly

Plagiocephaly is defined as an asymmetric skull deformity that is generally characterized by occipital flattening giving the head an oblique configuration.

Synostotic plagiocephaly occurs when there is a premature union of cranial sutures (coronal or lamboid). This pathological condition generally requires surgical intervention, with or without postoperative use of a cranial orthosis.

Positional plagiocephaly results from external pressure (molding) that causes the cranium, in which the premature union of the cranial sutures (coronal or lamboid) has not occurred, to become asymmetrical.

28.3.9.2.2​Authorization Requirements

Prior authorization is required for cranial molding orthosis which will be reviewed by the CSHCN medical director or designee. Prior authorization requests must be submitted on the CSHCN Services Program Authorization and Prior Authorization Request Form.

Cranial molding orthosis may be considered for prior authorization when they are part of a treatment plan for shaping the skull in cases of post-operative synostotic plagiocephaly or positional plagiocephaly with an associated functional impairment. Documentation that the use of the cranial molding orthosis will modify or prevent the development of such impairment is required.

Documentation supporting medical necessity must include all of the following:

•​Plan of treatment and/or follow up schedule

•​The assessment and recommendations of the appropriate primary care physician, pediatric sub-specialist, craniofacial team, or pediatric neurosurgeon

•​A full description of the physical findings, precise diagnosis, age of onset and the etiology of the deformity

•​Reports of any radiological procedures used in making the diagnosis

•​Client is at least 3 months of age, but not greater than 18 months of age

•​Anthropometric measurements documenting greater than 10 mm of cranial asymmetry

The written documentation of medical necessity must also include that aggressive repositioning interventions was attempted, with or without physical therapy, of at least three months’ duration without improvement in cranial asymmetry. The attempted aggressive repositioning interventions may include, but is not limited to:

•​Repositioning the client’s head to the opposite side of the preferred position when the infant is either lying down, reclined, or sitting.

•​Gently turning and stretching the client’s neck at each diaper change.

•​Repositioning the client’s bed, thus encouraging the infant to look away from the flattened side to view other objects of interest.

•​The trial of repositioning intervention has failed to improve the deformity and is judged to be unlikely to do so.

Repositioning may not be indicated for children who are over 6 months of age. Repositioning therapy for this age group may be waived with documentation of medical necessity.

Requests for clients with a comorbid diagnosis that prohibits repositioning will be evaluated on an individual basis.

Prior authorization requests for subsequent cranial molding orthosis must include documentation of medical necessity including new measurements.

Muscular torticollis (wry neck) characterized by tight or shortened neck muscles that result in a head tilt or turn, is often associated with the secondary development of positional plagiocephaly. Therefore, clients with muscular torticollis and positional plagiocephaly must have documentation of early, aggressive treatment (stretching, positioning and/or physiotherapy) prior to consideration of prior authorization for cranial orthosis.

28.3.9.3​Static and Dynamic Mechanical Stretching Devices

Static and dynamic mechanical stretching devices will be considered for prior authorization for a 3-month trial period when the request is submitted with the following documentation supporting medical necessity:

•​Client’s condition

•​Client’s current course of therapy

•​Rationale for the use of the static or dynamic mechanical stretching device

•​Agreement by the client or family that the client will comply with the prescribed use of the static or dynamic mechanical stretching device

Requests for purchase of the device must include documentation of successful completion of the 3-month trial period, with improvement in the client’s condition as measured by one of the following:

•​Demonstrated increase in range of motion

•​Demonstrated improvement in the ability to complete ADLs or perform activities outside the home

​Note:If the cost of the rental is expected to exceed the purchase price, purchase of the device should be considered.

Authorization requests for static or dynamic mechanical stretching devices must be submitted on the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME) Form.

​Refer to: Section 4.3, “Authorizations” in Chapter 4, “Prior Authorizations and Authorizations” for detailed information about authorization requirements.

28.4​Prostheses and Related Services

28.4.1​Prior Authorization and Documentation Requirements

Prior authorization is required for all prostheses and related services. All requests for prior authorization must include a valid prescription for the prosthetic device that is prescribed by a physician (M.D., D.O.).

​Note:The prescription must be maintained in the client’s medical record, and is valid for a maximum period of 6 months. At the end of the 6-month prescription period, additional prior authorization is required for any repairs, replacements, or related services.

Documentation of medical necessity must include, but is not limited to, documentation that the client meets the following general indications for the device:

•​The prosthesis replaces all or part of the function of a permanently inoperative, absent, or malfunctioning part of the limb.

•​The prosthesis is required for activities of daily living and/or for rehabilitation purposes.

The provider must maintain the following documentation in the client’s medical record:

•​The prescription for the requested prosthetic device

•​Written documentation of a rehabilitation program prescribed by the treating physician, including expected goals with the use of the prosthesis

•​Written documentation that the client or client’s family/caregiver is willing to comply with the rehabilitation program

28.4.2​Prostheses Procedure Codes

The following prostheses procedure codes may be reimbursed in the home setting to an orthotist, prosthetist, medical supplier (DME), and custom DME provider:

28.4.3​Preparatory or Temporary Prostheses

Preparatory or temporary prostheses are a benefit of the CSHCN Services Program.

A preparatory or temporary prosthesis allows for extensive gait training for lower-limb amputees and extensive functional training for upper-limb amputees. A preparatory prosthesis is intended as the final step before the permanent or definitive application. A client with a preparatory prosthesis does not need to be in the hospital, may be involved in chemotherapy or other medical or rehabilitative treatment that affects the size or healing of the residual limb, and may be undergoing changes to the residual limb that would preclude the fitting of the permanent or definitive prosthesis. A preparatory prosthesis is used by the client for varying time periods (4 to 12 months) before the permanent or definitive prosthesis needs to be ordered.

28.4.4​Upper-Limb Prostheses

Upper-limb prostheses will be considered for prior authorization with documentation of all of the indications defined in the Prostheses and Related Services section above. In addition, the following criteria apply for specific prosthetic devices.

28.4.4.1​Myoelectric Prostheses

Myoelectric upper extremity prostheses will be considered for prior authorization for clients with bilateral shoulder disarticulation.

Myoelectric hand prostheses will be considered for prior authorization for clients with traumatic or congenital absence of forearm(s) and hand(s).

28.4.5​Lower-Limb Prostheses

Lower-limb prostheses will be considered for prior authorization with documentation of all of the indications defined in Section 28.4.1, “Prior Authorization and Documentation Requirements” in this chapter. In addition, the following documentation is 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 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 may include the following:

•​The client’s history, including prior use of a prosthesis, if applicable

•​The client’s current condition, including the status of the residual limb, and any co-existing medical conditions

•​The client’s desire to ambulate

The following functional modifiers and levels have been defined by the Centers for Medicare & Medicaid Services (CMS):

A client whose functional level is zero is not a candidate for a prosthetic device; the device is not considered medically necessary. Advanced knee, ankle, or foot prostheses procedure codes must be submitted with the appropriate functional modifier in the table above.

28.4.5.1​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.

The licensed prosthetist or orthotist who provides the device must be trained in the fitting and programming of the microprocessor-controlled prosthetic device.

28.4.5.2​Foot Prostheses

The following foot prostheses will be considered for prior authorization for clients whose documented functional level is 1 or above:

•​A solid ankle-cushion heel (SACH) foot

•​An external keel SACH foot or single axis ankle/foot

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, multi-axial 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.

28.4.5.3​Knee Prosthesis

A single-axis, constant-friction knee or 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.

28.4.5.4​Ankle Prosthesis

An axial rotation unit will be considered for prior authorization for clients whose documented functional level is 2 or above.

28.4.5.5​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.

28.4.5.6​Accessories

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 artificial limb.

28.5​Repairs, Replacements, and Modifications to Orthoses and Prostheses

Repairs, replacements, and modifications to orthoses and prostheses are a benefit of the CSHCN Services Program when medically necessary criteria are met.

Repairs due to normal wear and modifications due to growth or change in medical status will be considered for prior authorization when the repair or modification is more cost-effective than the replacement of the device.

•​Additional information from the provider may be requested to determine cost-effectiveness.

•​Documentation supporting medical necessity must be provided when requesting prior authorization.

•​Replacement of orthotic or prosthetic devices will be considered for prior authorization with medical justification.

•​Orthotic devices are anticipated to last a minimum of 6 months from the receipt of the initial system.

•​Prosthetic devices are anticipated to last a minimum of one year from the receipt of the initial definitive/permanent system.

•​Preparatory or temporary prostheses may be replaced in less than 12 months of their receipt, but they will undergo medical review if the permanent prosthesis is requested less than 6 months after provision of the preparatory or temporary prosthesis.

•​Replacement of an orthosis or prosthesis will be considered when loss or irreparable damage has occurred due to a traumatic event such as a vehicle accident, a residential fire, or theft. A copy of the police or fire report is required when appropriate, along with the measures to be taken to prevent a repeat of similar loss.

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.

28.5.1​Other Artificial Devices

A prosthesis is defined as “a custom-fabricated or fitted medical device that is not surgically implanted and is used to replace a missing limb, appendage, or other external human body part, including an artificial limb, hand, or foot.“

The term “prosthesis” does not include an artificial eye, ear, finger, or toe, a dental appliance, a cosmetic device, including an artificial breast, eyelash, or wig, or other device that does not have a significant impact on the musculoskeletal functions of the body.

​Refer to: Section 40.2.1.9, “Eye Prostheses” in Chapter 40, “Vision Services” for information about eye prostheses.

Section 31.2.40, “Diagnostic and Surgical/Reconstructive Breast Therapies ” in Chapter 31, “Physician” and Chapter 17, “Durable Medical Equipment (DME)” for information about breast prostheses.

Chapter 14, “Dental” for information about dental services.

28.6​CSHCN Services Program Documentation of Receipt

The CSHCN Services Program Documentation of Receipt form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. Providers must retain individual delivery slips or invoices for each DOS that document the date of delivery for all supplies provided to a client and must disclose them to the CSHCN Services Program or its designee upon request.

The documentation of receipt form is available in both English and Spanish.

Documentation of delivery must include one of the following:

•​Delivery slip or invoice signed and dated by client/caregiver. The delivery slip or invoice must contain the client’s full name and address to which the supplies were delivered, the item description and the numerical quantities that were delivered to the client.

•​A dated carrier tracking document with shipping date and delivery date. The dated carrier tracking document must be attached to the delivery slip or invoice. The dated delivery slip or invoice must include an itemized list of goods that includes the descriptions and numerical quantities of the supplies delivered to the client. This document could also include prices, shipping weights, shipping charges, and any other description.

28.7​Claims Information

Orthotic and prosthetic services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

The HCPCS/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails.

​Refer to: Chapter 41, “TMHP Electronic Data Interchange (EDI)” for information about electronic claims submissions.

Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for general information about claims filing.

Section 5.7.2.4, “CMS-1500 Paper Claim Form Instructions” in Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement” for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

28.8​Reimbursement

Orthotics and prosthetics services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com.

The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/resources/rate-and-code-updates/rate-changes.

​Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

28.9​TMHP-CSHCN Services Program Contact Center

The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.