Cal. Code Regs. Tit. 22, § 51315 - Amount, Scope, Duration, Limitation and Prior Authorization of Benefits for Orthotic and Prosthetic Appliances and Services
(a) Orthotic and prosthetic appliances and
services, to the extent necessary for the restoration of function or
replacement of a body part(s), or to support a weakened or deformed body
member, are covered under the Medi-Cal program as follows:
(1) Except as specified in subsection (a)(2),
and subject to Welfare and Institutions Code, Section
14131.10,
which excludes coverage for podiatric and adult dental services (with
exemptions), when prescribed by a licensed physician, a licensed podiatrist, a
licensed dentist or a licensed non-physician medical practitioner, within the
scope of their license, and furnished by a certified orthotist, a certified
prosthetist, a certified orthotist/prosthetist, a licensed physician, a
licensed dentist, a licensed podiatrist or a certified pharmacy pursuant to
subsection (a)(3) below. A certified orthotist, prosthetist and
orthotist/prosthetist shall hold current certification from The American Board
for Certification in Orthotics, Prosthetics and Pedorthics or the Board of
Certification/Accreditation or their successor organizations.
(2) Stock orthopedic and stock conventional
shoes, pursuant to Section
51315.1(k)(3)(A),
are covered when prescribed by a licensed physician or a licensed podiatrist
and furnished by a certified orthotist, a certified prosthetist or a certified
orthotist/prosthetist.
(3) Orthotic
and prosthetic appliances and services listed in the Medi-Cal provider manual,
pursuant to Welfare and Institutions Code Section
14105.21,
may be furnished and billed by pharmacies, when the pharmacy is certified and
enrolled in the Medi-Cal program as a provider.
(b) A written prescription signed by a
licensed physician, a licensed podiatrist, a licensed dentist or a licensed
non-physician medical practitioner, and clinical notes/medical professional
records that document the medical necessity of the appliance or service, shall
be maintained by the provider in the patient's medical record, pursuant to
Section 51476. A copy of the written,
signed prescription or the electronic image/data transmission prescription in
accordance with Health and Safety Code, Section
11027
and documentation of medical necessity, as specified in subsection (c), shall
accompany the request for prior authorization, which is required under the
following circumstances:
(1) For orthotic
appliances each time the cumulative costs of purchase, replacement, and repair
exceed $250.00 per patient, per provider, per 90-day period. This 90-day period
of time shall begin on the date of the first service after the close of the
previous 90-day period of time during which a service, if any, was
provided.
(2) For prosthetic
appliances each time the cumulative costs of purchase, replacement, and repair
exceed $500.00 per patient, per provider, per 90-day period. This 90-day period
of time shall begin on the date of the first service after the close of the
previous 90-day period of time during which a service, if any, was
provided.
(3) For orthotic and
prosthetic appliances and services where there is no allowable listed procedure
code or rate of reimbursement pursuant to Welfare and Institutions Code Section
14105.21(c).
(c) The prior authorization request for
orthotic and prosthetic appliances and services shall be authorized when
documentation includes the type of appliance or service; the medical diagnosis,
and prognosis; an explanation of the purpose for the appliance or service; and
substantiation that the criteria specified in subsection (c)(1) through (5)
below, and the criteria specified in Section
51315.1 for orthotic appliances
and services, or the criteria specified in Section
51315.2 for prosthetic appliances
and services are met.
(1) The appliance or
service is medically necessary for the restoration of bodily functions, to
support a weakened or deformed body member or for the replacement of a body
part and is reasonable and necessary to protect life, to prevent significant
illness or disability, or to alleviate severe pain.
(2) The appliance or service is essential to
performing activities of daily living or instrumental activities of daily
living.
(3) The appliance or
service is consistent with the patient's previous abilities and limitations, as
they relate to activities of daily living or instrumental activities of daily
living, prior to the onset of disability or injury, or as appropriate to the
patient's chronological and developmental age.
(4) The appliance or service is consistent
with the patient's overall medical condition.
(5) The appliance or service is the lowest
cost appliance or service that meets the patient's medical
need(s).
(d) Prior
authorization of orthotic and prosthetic appliances and services shall not be
granted for any of the following:
(1) Backup
appliances, except when the primary appliance must be worn by the patient 24
hours per day or when the appliance must be cleaned on a regular basis and
cannot be dried overnight.
(2)
Appliances or services for the sole purpose of cosmetic restoration in the
absence of medical necessity as described in subsection (c)(1).
(3) Appliances or services for the sole
purpose of restoring functions beyond activities of daily living or
instrumental activities of daily living, such as athletic activities.
(4) Appliances or services when the appliance
or service is a benefit that is included as part of the acute inpatient
hospital stay and the date of service occurs during that stay.
(5) Repair of an appliance when the repair
cost is equal to, or greater than, the cost of purchasing a new
appliance.
(6) Purchase or
replacement of an appliance when the patient's existing appliance can be
repaired at a cost less than the cost of purchasing a new appliance, unless the
existing appliance does not meet the patient's medical need(s), as documented
by the licensed physician, licensed podiatrist, licensed dentist or licensed
non-physician medical practitioner.
(7) Fitting, measuring, training or delivery
of the appliance separate from the prior authorization of the appliance
itself.
(e) Reimbursement
for orthotic and prosthetic appliances and services shall be subject to the
following:
(1) Shall not exceed 80 percent of
the lowest maximum allowance for California established by the federal Medicare
program for the same or similar appliances or services.
(2) When there is no comparable
Medicare-reimbursed appliance or service, reimbursement shall not exceed an
amount that is the lowest of:
(A) The usual
charges made to the general public for the provision of the same or similar
appliances or services, or
(B) The
maximum reimbursement rates listed in the Medi-Cal provider
manual.
(3) Maximum
reimbursement rates are for the base appliance and for any component parts that
may be added to the base appliance. When applicable, billings shall include
both the base appliance and the component parts necessary to complete the
prescribed appliance.
(4) Orthotic
and prosthetic appliances and services that do not require prior authorization
shall meet the requirements under Section
51315(c).
Notes
2. Amendment of subsection (d) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
3. Amendment of subsection (a) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
4. Change without regulatory effect of NOTE (Register 86, No. 49).
5. Amendment of subsection (a) filed 5-25-89; operative 6-24-89 (Register 89, No. 21.)
6. Amendment of subsection (a) and NOTE, designation and amendment of subsections (a)(1)(A) and (B), and new subsections (a)(1) and (a)(2)-(a)(2)(B) filed 9-14-92; operative 10-14-92 (Register 92, No. 38).
7. Amendment of subsections (a)(2)-(a)(2)(B) filed 3-24-93; operative 4-23-93 (Register 93, No. 13).
8. Change without regulatory effect amending subsection (a)(2) and NOTE filed 3-8-94 pursuant to title 1, section 100, California Code of Regulations (Register 94, No. 10).
9. Editorial correction reinstating inadvertently omitted subsections (b)-(d)(2) (Register 97, No. 37).
10. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed 7-17-2003 as an emergency; operative 7-17-2003 (Register 2003, No. 29). A Certificate of Compliance must be transmitted to OAL by 1-13-2004 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of HISTORY 10 (Register 2003, No. 33).
12. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed 1-14-2004 as an emergency; operative 1-14-2004 (Register 2004, No. 3). A Certificate of Compliance must be transmitted to OAL by 7-12-2004 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 1-14-2004 order, including further amendment of subsections (a)-(a)(2), new subsections (e)-(f)(4) and amendment of NOTE, transmitted to OAL 7-12-2004 and filed 8-12-2004 (Register 2004, No. 33).
14. Amendment of section heading, section and NOTE filed 10-2-2015; operative 1-1-2016 (Register 2015, No. 40).
Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14103.7, 14105, 14105.21, 14132, 14132.10, 14132.765, 14133, 14133.1, 14133.3 and 14133.9, Welfare and Institutions Code.
2. Amendment of subsection (d) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
3. Amendment of subsection (a) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
4. Change without regulatory effect of NOTE (Register 86, No. 49).
5. Amendment of subsection (a) filed 5-25-89; operative 6-24-89 (Register 89, No. 21.)
6. Amendment of subsection (a) and Note, designation and amendment of subsections (a)(1)(A) and (B), and new subsections (a)(1) and (a)(2)-(a)(2)(B) filed 9-14-92; operative 10-14-92 (Register 92, No. 38).
7. Amendment of subsections (a)(2)-(a)(2)(B) filed 3-24-93; operative 4-23-93 (Register 93, No. 13).
8. Change without regulatory effect amending subsection (a)(2) and Note filed 3-8-94 pursuant to title 1, section 100, California Code of Regulations (Register 94, No. 10).
9. Editorial correction reinstating inadvertently omitted subsections (b)-(d)(2) (Register 97, No. 37).
10. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of Note filed 7-17-2003 as an emergency; operative 7-17-2003 (Register 2003, No. 29). A Certificate of Compliance must be transmitted to OAL by 1-13-2004 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of History 10 (Register 2003, No. 33).
12. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of Note filed 1-14-2004 as an emergency; operative 1-14-2004 (Register 2004, No. 3). A Certificate of Compliance must be transmitted to OAL by 7-12-2004 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 1-14-2004 order, including further amendment of subsections (a)-(a)(2), new subsections (e)-(f)(4) and amendment of Note, transmitted to OAL 7-12-2004 and filed 8-12-2004 (Register 2004, No. 33).
14. Amendment of section heading, section and Note filed 10-2-2015; operative
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