Orthotic appliances and services shall be authorized
under the Medi-Cal program when the supporting documentation and all other
requirements specified in Section
51315 and in this section are
met.
For purposes of this section, medical conditions cited
with each appliance/service or group of appliances/services shall not be
construed to represent an exhaustive list of medical conditions appropriate to
each appliance/service or group of appliances/services. Likewise, such medical
conditions may not be appropriate for authorization of the requested
appliance/service if medical necessity for the specific appliance/service is
not documented.
(a) Shoe Supplies for
Diabetics shall include shoes and their fitting(s), modifications and inserts;
and shall be authorized when the patient has a diagnosis of diabetes mellitus
and requires one or more of the following shoe(s), shoe modification(s) or shoe
insert(s) to accommodate for or prevent foot ulceration and related foot
conditions:
(1) For prefabricated shoe(s) or
shoe insert(s), or modification(s) to prefabricated shoe(s) or shoe insert(s),
the patient has one or more of the following medical conditions, appropriate to
the requested procedure code(s):
(A) Foot
ulcer(s).
(B) Previous amputation
of the contralateral foot, or part of either foot, due to microvascular disease
secondary to diabetes.
(C) History
of foot ulceration(s) of either foot.
(D) Peripheral neuropathy with evidence of
callous formation of either foot.
(E) Deformity of either foot, such as rocker
bottom foot or Charcot foot.
(F)
Compromised vascular disease in either foot.
(G) Positive monofilament examination
indicating diabetic neuropathy.
(2) For custom-made shoe(s) or shoe
insert(s), or modification(s) to custom-made shoe(s) or shoe insert(s), the
patient has one or more of the listed medical conditions in subsection (a)(1),
and one or more of the following, appropriate to the requested procedure
code(s):
(A) Neurological
manifestation(s).
(B) Peripheral
circulatory disorder(s).
(C)
Treatment or prevention of other foot conditions secondary to diabetes
mellitus.
(b)
Compression Burn Garments shall be authorized when the patient requires a
custom-fabricated garment to provide physician-ordered compression to
facilitate the healing of burn tissue or a similar injury, or to prevent
scarring.
(c) Gradient Compression
Stockings shall include custom-made stockings and garter belts and shall be
authorized when one or both of the following criteria is met, appropriate to
the requested procedure code(s):
(1) For
custom-made compression stockings, the patient has a medical condition that
results in symptomatic venous insufficiency or lymphedema in one or both lower
extremities that requires the use of a custom-made compression
stocking(s).
(2) For garter belts,
the patient has an existing or authorized compression stocking or residual limb
shrinker and requires the use of a garter belt to hold the compression stocking
or shrinker in place.
(d)
Spinal Orthoses shall include all of the following:
(1) Cranial Orthoses (helmets) shall be
authorized when cranial molding is required in children two years of age and
younger with plaglocephaly or craniosynostosis. For purposes of cranial molding
in children, the appliance shall be manufactured by a Federal Drug
Administration-approved laboratory.
(2) Cervical and Multiple Post Collar
Orthoses (collars) shall be authorized when the patient has a medical
condition(s) or a medical need(s) that requires support to the cervical spine
to decrease pain, to increase functional capacity, or to prevent or ameliorate
further injury, such as one of the following, appropriate to the requested
procedure code(s):
(A) Whiplash or other
injury to the neck.
(B)
Post-surgical repair of a cervical fracture.
(C) Post-surgical treatment of a ligamentis
injury or torticollis.
(D)
Treatment in place of surgical intervention for a cervical fracture or
ligamentis injury.
(E) Any related
medical condition that requires support to the cervical
spine.
(3) Thoracic
Orthoses (rib belts) shall be authorized when the patient has a medical
condition that requires support to the thoracic area to decrease pain, to
increase functional capacity, or to prevent or ameliorate further injury, such
as for fractured ribs or torn intercostal ligaments.
(4) Thoracic Orthoses
(anterior-posterior-lateral-rotary control) shall be authorized when both of
the following criteria are met:
(A) The
patient has one of the following medical conditions:
1. A slipped or herniated disk.
2. Osteoporosis of the thoracic
area.
3. A vertebral fracture, with
or without surgery.
4. A related
medical condition of the thoracic area.
(B) The patient requires one or more of the
following treatments to decrease pain, to increase functional capacity, or to
prevent or ameliorate further injury, appropriate to the requested procedure
code(s):
1. Trunk support.
2. Reduction of load on the intervertebral
discs.
3. Reduction of gross trunk
motion in the sagittal plane.
(5) Thoracic Orthoses (triplanar control --
modular segmented spinal system [prefabricated]) shall be authorized when both
of the following criteria are met:
(A) The
patient has one or more of the following medical conditions:
1. Post neck or back surgery.
2. Post laminectomy.
3. A vertebral fracture.
4. A related medical condition of the
thoracic area.
(B) The
patient requires one or both of the following treatments to decrease pain, to
increase functional capacity, or to prevent or ameliorate further injury:
1. Reduction of gross trunk motion in three
planes (sagittal, coronal and transverse).
2. Spinal support and stabilization or
immobilization of the spine.
(6) Thoracic Orthoses (triplanar control --
rigid frame) shall be authorized when the patient has a medical condition that
requires one or more of the following treatments to decrease pain, to increase
functional capacity, or to prevent or ameliorate further injury, appropriate to
the requested procedure code(s):
(A) Reduction
of load on the intervertebral discs.
(B) Reduction of gross trunk motion in three
planes (sagittal, coronal and transverse).
(C) Hyperextension of the thoracic, lumbar
and sacral areas of the back.
(7) Thoracic Orthoses (triplanar control --
rigid plastic shell) shall be authorized when the patient has one of the
following medical conditions that requires reduction of gross trunk motion in
three planes (sagittal, coronal and transverse) when spinal support and
immobilization are required to decrease pain, to increase functional capacity,
or to prevent or ameliorate further injury:
(A) Post neck surgery.
(B) Post back surgery (laminectomy or
vertebral fracture).
(C) A related
medical condition of the neck or back.
(e) Thoracic Orthoses (sagittal or
sagittal-coronal control) shall be authorized when the patient has a medical
condition that requires one or more of the following treatments to decrease
pain, to increase functional capacity, or to prevent or ameliorate further
injury, appropriate to the requested procedure code(s):
(1) Reduction of load on the intervertebral
discs.
(2) Reduction of gross trunk
motion in the sagittal plane.
(3)
Reduction of gross trunk motion in the sagittal and coronal
planes.
(f)
Cervical-Thoracic-Lumbar-Sacral Orthoses shall include all of the following:
(1) Sacroiliac Orthoses shall be authorized
when the patient has a medical condition that requires one or more of the
following treatments to decrease pain, to increase functional capacity, or to
prevent or ameliorate further injury:
(A)
Support to the pelvic-sacral area.
(B) Reduction of gross trunk motion of the
sacroiliac joint.
(C) Pendulous
abdomen support, such as in severe ptosis.
(2) Lumbar Orthoses shall be authorized when
the patient has a medical condition that requires one or more of the following
treatments to decrease pain, to increase functional capacity, or to prevent or
ameliorate further injury, appropriate to the requested procedure code(s):
(A) Support to the lumbar area.
(B) Reduction of load on the intervertebral
discs.
(C) Reduction of gross trunk
motion in the sagittal plane.
(D)
Pendulous abdomen support, such as in severe ptosis.
(3) Lumbar-Sacral Orthoses shall be
authorized when the patient has a medical condition that requires one or more
of the following treatments to decrease pain, to increase functional capacity,
or to prevent or ameliorate further injury, appropriate to the requested
procedure code(s):
(A) Support to the
lumbar-sacral areas.
(B) Reduction
of load on the intervertebral discs.
(C) Reduction of gross trunk motion in the
sagittal or coronal plane.
(D)
Flexion of the lumbar spine.
(E)
Pendulous abdomen support, such as in severe ptosis.
(4) Anterior-Posterior-Lateral Control
Orthoses shall be authorized when the patient has a medical condition that
requires support and maximum external restriction of anterior, posterior and
lateral motion to the cervical, thoracic, lumbar and sacral spine to decrease
pain, to increase functional capacity, or to prevent or ameliorate further
injury.
(g) Halo
Procedures shall include the base appliance and additions, and shall be
authorized when one or both of the following criteria is met, appropriate to
the requested procedure code(s):
(1) For the
base appliance, the patient has a medical condition that requires support and
maximum external restriction of anterior, posterior and lateral motion to the
cervical, thoracic, lumbar and sacral spine to decrease pain, to increase
functional capacity, or to prevent or ameliorate further injury.
(2) For the addition(s), all of the following
are met:
(A) The patient's medical condition
requires the specific function for which the addition(s) was
designed.
(B) The addition(s) is
required by the patient to improve the functionality of the halo procedure,
without which the patient's medical need(s) would not be met.
(C) The patient has an existing or authorized
halo procedure that is compatible with the
addition(s).
(h) Additions to Spinal Orthoses shall be
authorized when all of the following criteria are met:
(1) The patient's medical condition requires
the specific function for which the addition(s) was designed.
(2) The addition(s) is required by the
patient to improve the functionality of the spinal orthosis, without which the
patient's medical need(s) would not be met.
(3) The patient has an existing or authorized
spinal orthosis that is compatible with the addition(s).
(i) Orthotic Devices -- Scoliosis Procedures
shall include all of the following:
(1)
Cervical-Thoracic-Lumbar-Sacral Orthoses.
(A)
Shall include all of the following:
1. The
Infant Immobilizer shall be authorized only for children under one year of age
for stabilization of the cervical spine, upper thoracic spine and airway. The
infant immobilizer shall not be authorized for use in restraining infants
during surgical or radiological procedures.
2. The Tension Based Scoliosis Orthosis shall
be authorized only for a child diagnosed with adolescent idiopathic scoliosis
or a similar deformity or disease.
3. Additions to
Cervical-Thoracic-Lumbar-Sacral Orthoses or Scoliosis Orthoses shall be
authorized when all of the following criteria are met:
a. The patient's medical condition requires
the specific function for which the addition(s) was designed.
b. The addition(s) is required by the patient
to improve the functionality of the cervical-thoracic-lumbar-sacral orthosis or
scoliosis orthosis, without which the patient's medical need(s) would not be
met.
c. The patient has an existing
or authorized cervical-thoracic-lumbar-sacral orthosis or scoliosis orthosis
that is compatible with the addition(s).
(B) Shall be authorized when both of the
following criteria are met:
1. The patient has
a diagnosis of scoliosis or other curvature or instability of the
spine.
2. The appliance is
appropriate for the patient's degree and type of scoliosis, or spinal curvature
or instability in which the degree of spinal curvature or instability, any
lower extremity length discrepancy, and goals of treatment are
considered.
(2)
Thoracic-Lumbar-Sacral Orthoses (Low Profile) shall include the base appliance
and additions, and shall be authorized when one or both of the following
criteria is met, appropriate to the requested procedure code(s):
(A) For the base appliance, both of the
following criteria are met:
1. The patient
has a diagnosis of scoliosis or other curvature or instability of the
spine.
2. The base appliance is
appropriate for the patient's degree and type of scoliosis or spinal curvature
or instability in which the degree of spinal curvature or instability, any
lower extremity length discrepancy, and goals of treatment are
considered.
(B) For the
addition(s), all of the following criteria are met:
1. The patient has a diagnosis of scoliosis
or other curvature or instability of the spine.
2. The patient's medical condition requires
the specific function for which the addition(s) was designed.
3. The addition(s) is required by the patient
to improve the functionality of the thoracic-lumbar-sacral orthosis, without
which the patient's medical need(s) would not be met.
4. The patient has an existing or authorized
thoracic-lumbar-sacral orthosis that is compatible with the
addition(s).
(3) Other Scoliosis Procedures (body jackets)
shall be authorized when both of the following criteria are met:
(A) The patient has a diagnosis of scoliosis
or other curvature or instability of the spine.
(B) The appliance is appropriate for the
patient's degree and type of scoliosis or spinal curvature or instability in
which the degree of spinal curvature or instability, any lower extremity length
discrepancy, and goals of treatment are
considered.
(j)
Orthotic Devices -- Lower Limb (Extremity) shall include all of the following:
(1) Hip Orthoses -- Flexible shall be
authorized when both of the following criteria are met:
(A) The patient has one of the following
medical conditions:
1. Congenital hip
dislocation or hip dysplasia in infants and children.
2. Post total hip replacement when
post-operative hip stabilization is necessary to prevent dislocation or to
facilitate healing of a fracture.
3. An injured or previously dislocated hip
that requires rehabilitation as an alternative to surgery.
4. A related medical condition that requires
control and stabilization of the hip(s).
(B) The patient requires one of the following
treatments to decrease pain, to increase functional capacity, or to prevent or
ameliorate further injury, appropriate to the requested procedure code(s):
1. Abduction control, with or without
ambulation.
2. Post-operative
control of hip motion.
3. Control
of adduction or rotational guidance of both hips.
(2) Legg Perthes Orthoses shall be authorized
when the patient has a diagnosis of Legg-Calve-Perthes deformity or similar
deformity or disease, and requires control of hip abduction, adduction or
weight bearing, appropriate to the requested procedure code(s).
(3) Knee Orthoses shall be authorized when
both of the following criteria are met:
(A)
The patient has a deformity or injury of, or affecting the knee, such as one of
the following:
1. Post surgical repair of
ligament tears.
2. Post
arthroscopy.
3. Osteoarthritis or
other degenerative joint disease.
4. Post polio.
5. Rehabilitation of an injured
knee.
6. Any related medical
condition affecting the knee.
(B) The patient requires one or more of the
following treatments to decrease pain, to increase functional capacity, or to
prevent or ameliorate further injury, appropriate to the requested procedure
code(s):
1. Support or protection of the
knee.
2. Control or restriction of
motion of the knee.
3.
Medial-lateral and rotation control of the knee.
4. Sagittal plane control of the
knee.
5. Prevention or control of
recruvatum (hyperextension of the knee).
6. Control of hip flexion in
bed.
(4)
Ankle-Foot Orthoses shall be authorized when the patient has a disease,
deformity, injury or condition of, or affecting the lower extremity in which
the patient experiences pain or diminished functional capacity of the lower
extremity and requires one or more of the following treatments, appropriate to
the requested procedure code(s):
(A)
Assistance in specific movements of the ankle and foot.
(B) Support to the ankle and foot.
(C) Maintenance of the foot in a neutral or
functional position.
(D)
Stabilization of the knee or hip.
(E) Control of movement of the ankle and
foot.
(5) Knee-Ankle-Foot
Orthoses -- or Any Combination shall be authorized when the patient has a
disease, deformity, injury or condition of, or affecting the knee or ankle
joint(s) in which the patient experiences pain or diminished functional
capacity of the knee or ankle joint(s) and requires one or more of the
following treatments, appropriate to the requested procedure code(s):
(A) Control of motion of the knee, ankle or
foot.
(B) Maintenance of the ankle
and foot in a fixed position.
(C)
Correction of contractures of the knee and ankle joints.
(6) Torsion Control: Hip-Knee-Ankle-Foot
Orthoses shall be authorized when the patient has a disease, deformity, injury
or condition of, or affecting the hip, knee or ankle joint(s) in which the
patient experiences pain or diminished functional capacity of the hip, knee or
ankle joint(s) and requires control in rotation of one or both hips,
appropriate to the requested procedure code(s).
(7) Torsion Control: Hip-Knee-Ankle-Foot
Orthoses (Tibial Fracture Cast) shall be authorized when the patient has a
fracture of the tibia or fibula and requires support and stabilization of the
fracture site to facilitate healing, to decrease pain, to increase functional
capacity, or to prevent or ameliorate further injury.
(8) Torsion Control: Hip-Knee-Ankle-Foot
Orthoses (Femoral Fracture Cast) shall be authorized when the patient has a
fracture of the femur and requires support and stabilization of the fracture
site to facilitate healing, to decrease pain, to increase functional capacity,
or to prevent or ameliorate further injury.
(9) Reciprocating Gait Orthoses shall be
authorized when chronologically and developmentally appropriate (beginning
around two years of age and up) and all of the following criteria are met:
(A) The patient has both of the following
conditions:
1. Thoracic or upper lumbar spine
lesions with spasticity.
2. Range
of motion limitations that nevertheless allow joints to be put in appropriate
position for ambulation.
(B) The patient does not have any of the
following conditions or contraindications:
1.
Severe irreducible contractures that prevent establishing normal
alignment.
2. Severe spasticity or
other involuntary muscle activity that prevents free and coordinated
mobility.
3. Severe
obesity.
4. Poor upper extremity
strength.
5. Advanced
osteoporosis.
6. A fracture(s) or a
history of fracture(s).
7. History
of not following treatment plans (noncompliance).
8. A pressure sore(s) in an area(s) that
would be in contact with the orthosis.
(C) Documentation in the patient's medical
record substantiates all of the following:
1.
Cardiopulmonary integrity.
2. That
no other orthosis will meet the patient's medical need(s).
3. Spinal cord injury level above the third
lumbar vertebrae.
4. No
contractures and muscle atrophy that would preclude the use of the
reciprocating gait orthosis.
5.
Stability of the spine.
6. No
advanced osteoporosis or fracture(s).
7. One of the following diagnoses:
a. Paraplegia (diagnosis code
344.1).
b. Spina bifida, without
mention of hydrocephalus, dorsal [thoracic] region (diagnosis code
741.92).
c. Spina bifida, without
mention of hydrocephalus, lumbar region (diagnosis code 741.93).
d. Any related medical condition affecting
the spine.
(D)
For patients 21 years of age and older, in addition to the documentation
requirements specified in subsection (j)(9)(C)1. through 7., all of the
following shall also be documented in the patient's medical record:
1. Plantigrade feet.
2. Minimal contractures in the knees and
hips.
3. Flexible hips without
rigidity or spasticity.
4. Good
upper extremity strength.
5.
Realistic goals and expectations and a family or other support
system.
(10)
(A) Orthotic Devices -- Lower Limb
(Extremity) (Additions to Lower Extremity Orthoses) shall include all of the
following:
1. Additions to Fracture
Orthoses.
2. Additions to Lower
Extremity Orthoses: Shoe-Ankle-Shin-Knee.
3. Additions to Straight Knee or Offset Knee
Joints (Knee Joints).
4. Additions:
Thigh-Weight Bearing -- Gluteal/Ischial Weight Bearing.
5. Additions: Pelvic and Thoracic
Control.
6. Additions:
General.
7. Custom Foot
Orthoses.
(B) Shall be
authorized when all of the following criteria are met, appropriate to the
requested procedure code(s):
1. The patient's
medical condition requires the specific function for which the addition(s) was
designed.
2. The addition(s) is
required by the patient to improve the functionality of the lower extremity
orthosis, without which the patient's medical need(s) would not be
met.
3. The patient has an existing
or authorized lower extremity orthosis that is compatible with the
addition(s).
(C) In
addition to the criteria specified in paragraph (B) above, paragraph (A)7.
(Custom Foot Orthoses) shall be authorized when the orthosis is fabricated for
a patient using the patient's individual measurements or pattern. This
fabrication shall be constructed using a plaster casting of the patient's foot
to create a mold, or with a three-dimensional negative impression or digital
scanning (Computer-Aided Design/Computer Aided Manufacture Model [CAD/CAM]).
The use of foam boxes shall not be an acceptable fabrication
method.
(k)
Orthopedic Shoes shall include all of the following:
(1) Hallux-Valgus Splint shall be authorized
when the patient has a medical condition of the foot that requires a custom
fitted orthosis to hold the big toe in the proper anatomical
position.
(2) Abduction and
Rotation Bars shall be authorized when the patient has a medical condition of
the foot (feet) that requires one or both of the following treatments to
decrease pain, to increase functional capacity, or to prevent or ameliorate
further injury, appropriate to the requested procedure code(s):
(A) Increased internal or external rotation
of the foot (feet).
(B) Independent
positioning of the hind foot and forefoot for adduction or
abduction.
(3) Orthopedic
Footwear shall include both of the following:
(A) Stock Orthopedic Shoes and Stock
Conventional Shoes shall include in-depth shoes, and shall be authorized when
both of the following criteria are met:
1. At
least one of the shoes is attached to a prosthesis or brace. For purposes of
this subsection, the following definitions shall apply:
a. A "brace" means an orthosis involving the
foot that extends above the ankle and is made of metal or other durable rigid
material that immobilizes, restricts movement in a given direction, controls
mobility, assists with movement, reduces weight-bearing forces or holds body
parts in the correct position.
b.
"Attached to a prosthesis or brace" means the prosthesis or brace is
permanently affixed to the shoe as an integral part of the
shoe.
2. The patient has
a medical condition of the foot (feet) that requires one or more of the
following treatments, appropriate to the requested procedure code(s):
a. Increased pronation or supination of the
foot (feet).
b. Post surgical
footwear to allow for changes in volume of the foot (feet).
c. A shoe that holds the heel firmly in
place.
d. A firm heel counter and a
strong shank.
e. Accommodation of a
deformed foot (feet) or a foot orthosis(es).
f. Footwear to allow for changes in volume,
fractures, amputation or ulcers of the foot
(feet).
(B)
Custom-Made Orthopedic Shoes shall include both the base shoe(s) and any
required addition(s) to the base shoe(s):
1.
The base shoe(s) shall be authorized when both of the following criteria are
met:
a. The patient does not require a
shoe(s) provided under the diabetic footwear program covered under subsection
(a), but has a medical need(s) that cannot be met by modification(s) to a stock
orthopedic or stock conventional shoe(s) covered under subsections (k)(3)(A)
and (k)(4). The prescribing practitioner shall document the nature, cause and
severity of the foot problem(s) that substantiates the requirement for a
custom-made shoe(s), such as one of the following medical conditions:
i. Charcot or rheumatoid foot
deformities.
ii. Partial foot
amputation.
iii. Post muscle flap
surgery to cover a large or unusual soft tissue foot defect.
iv. A related medical condition that requires
a custom-made orthopedic shoe(s),
b. The patient's medical condition of the
foot (feet) requires one or more of the following accommodations, appropriate
to the requested procedure code(s):
i. A
severely deformed foot (feet).
ii.
A toe or distal partial foot amputation.
iii. A sensitive foot (feet), or a pressure
sore(s) or area(s).
iv. A related
foot condition.
2. The base shoe(s) shall be authorized when
it has all of the following characteristics:
a. Made and molded to the patient model for a
specific patient.
b. Constructed
over a positive model of the patient's foot.
c. Made from leather or other suitable
material of equal or better quality.
d. Has removable inserts as an integral part
of the shoe that can be altered or replaced as the patient's condition
warrants.
e. Has some form of shoe
closure.
3. The
addition(s) to the base shoe shall be authorized when all of the following
criteria are met:
a. The patient's medical
condition requires the specific function for which the addition(s) was
designed.
b. The addition(s) is
required by the patient to improve the functionality of the custom-made
orthopedic shoe(s), without which the patient's medical need(s) would not be
met.
c. The patient has an existing
or authorized custom-made orthopedic shoe(s) that is compatible with the
addition(s).
(4) Shoe Modifications of Stock Orthopedic
Shoes and Stock Conventional Shoes, including additions, modifications and
services:
(A) Shall include all of the
following:
1. Shoe Modifications --
Lifts.
2. Shoe Modifications --
Wedges.
3. Shoe Modifications --
Heels.
4. Orthopedic Shoe
Additions.
5. Transfer or
Replacement. For purposes of subsection (k)(4), the terms "Transfer" and
"Replacement" mean standard laboratory procedures for general shoe work for the
purpose of transfer and fixation of an orthosis from one shoe to
another.
(B) Shall be
authorized when all of the following criteria are met:
1. The patient's medical condition requires
the specific function for which the addition(s), modification(s) or service(s)
was designed.
2. The addition(s),
modification(s) or service(s) is required by the patient to improve the
functionality of the shoe(s), without which the patient's medical need(s) would
not be met.
3. The patient has an
existing or authorized shoe(s) that is compatible with the addition(s),
modification(s) or service(s).
(l) Orthotic Devices -- Upper Limb shall
include all of the following:
(1) Shoulder
Orthoses shall be authorized when the patient has a medical condition of, or
affecting the shoulder joint that requires that the shoulder be held in place
to prevent or limit motion in order to protect the shoulder joint from injury
or provide support/stabilization during functional activities.
(2) Elbow Orthoses shall include elbow
orthoses, elbow-wrist-hand orthoses and elbow-wrist-hand-finger orthoses, and
shall be authorized when the patient has a medical condition of, or affecting
the elbow, wrist, hand or finger joint(s) that requires support, stabilization,
restriction or enhancement of movement of the elbow, wrist, hand or finger
joint(s) to decrease pain, to increase functional capacity, or to prevent or
ameliorate further injury, appropriate to the requested procedure
code(s).
(3) Wrist-Hand-Finger
Orthoses shall be authorized when the patient has a medical condition of, or
affecting the wrist, hand or finger(s) that requires support, stabilization,
restriction or enhancement of movement of the wrist, hand or finger(s) to
decrease pain, to increase functional capacity, or to prevent or ameliorate
further injury, appropriate to the requested procedure code(s).
(4) Additions to Upper Limb Orthoses shall be
authorized when all of the following criteria are met:
(A) The patient's medical condition requires
the specific function for which the addition(s) was designed.
(B) The addition(s) is required by the
patient to improve the functionality of the upper extremity wrist, finger or
elbow joint(s), without which the patient's medical need(s) would not be
met.
(C) The patient has an
existing or authorized upper extremity orthosis that is compatible with the
addition(s).
(5) Dynamic
Flexor Hinge, Reciprocal Wrist Extension/Flexion, Finger Flexion/Extension
Orthoses shall be authorized when the patient has a medical condition of, or
affecting the wrist, hand or finger(s) that requires a custom-made orthosis to
hold the hand, finger or wrist in a prescribed position and to enhance and
control movement of the hand, finger or wrist.
(6) External Power shall be authorized when
both of the following criteria are met:
(A)
The patient has a medical condition of, or affecting the wrist, hand or
finger(s) that requires a custom-made, electrically powered wrist-hand-finger
orthosis to allow effective movement of the wrist, hand or finger(s) in the
performance of activities of daily living or instrumental activities of daily
living.
(B) The patient is not able
to otherwise effectively use a manually operated orthosis.
(7) Other Wrist-Hand-Finger Orthoses --
Custom Fitted shall include both of the following:
(A) Custom Fitted Wrist-Hand-Finger Orthoses
shall be authorized when the patient has a medical condition of, or affecting
the wrist, hand or finger(s) that requires a custom-fitted orthosis to provide
support, stabilization, restriction or enhancement of movement of the wrist,
hand or finger(s), appropriate to the requested procedure code(s).
(B) Addition of a joint(s) to an upper
extremity orthosis shall be authorized when all of the following criteria are
met:
1. The patient has a medical condition
that requires the specific function for which the joint(s) was
designed.
2. The joint(s) is
required by the patient to improve the functionality of the upper extremity
orthosis, without which the patient's medical need(s) would not be
met.
3. The patient has an existing
or authorized upper extremity orthosis that is compatible with the
joint(s).
(m) Shoulder-Elbow-Wrist-Hand Orthoses shall
include all of the following:
(1) Abduction
Position, Custom Fitted Orthoses shall be authorized when both of the following
criteria are met:
(A) The patient has a
medical condition of, or affecting the shoulder, elbow, wrist or hand, such as
one of the following:
1. Post surgery of the
shoulder, elbow or wrist joint(s).
2. Treatment of Erbs Palsy.
3. A related medical condition of the
shoulder, elbow or wrist joints.
(B) The patient requires a custom-fitted
orthosis to provide positioning, stabilization or restriction of movement of
the shoulder, elbow, wrist or hand, appropriate to the requested procedure
code(s).
(2) Mobile Arm
Supports shall be authorized when the patient meets the criteria specified in
paragraph (1) above and requires such support attached to a wheelchair, chair
or table.
(3) Additions to Mobile
Arm Supports shall include both additions and adaptations to the mobile arm
support or the addition(s), and shall be authorized when all of the following
criteria are met:
(A) The patient's medical
condition requires the specific function for which the addition(s) or
adaptation(s) was designed.
(B) The
addition(s) or adaptation(s) is required by the patient to improve the
functionality of the mobile arm support, without which the patient's medical or
functional need(s) would not be met.
(C) The patient has an existing or authorized
mobile arm support that is compatible with the addition(s) or
adaptation(s).
(4)
Fracture Orthoses shall be authorized when the patient has a fracture of the
upper extremity and requires support and stabilization of the fracture site to
facilitate healing, to decrease pain, to increase functional capacity, or to
prevent or ameliorate further injury, appropriate to the requested procedure
code(s).
(n) Repairs for
orthotic appliances shall include repairs, maintenance, replacements and
associated labor, and shall be authorized when all of the following criteria
are met:
(1) The patient has an existing
orthosis that requires repair, maintenance or replacement.
(2) The repair, maintenance or replacement
cost(s), including the associated labor is less than the cost(s) of purchasing
a new orthotic appliance.
(3) The
request or claim includes a list of the components to be repaired or replaced
and a statement explaining the necessity for the repair or
replacement.
(o)
Ancillary Orthotic Devices shall be authorized when the patient has a medical
condition that requires an upper or lower extremity orthosis not otherwise
covered under this section to provide support and positioning to an upper or
lower extremity joint(s), appropriate to the requested procedure
code(s).
(p) Trusses shall be
authorized when the patient has an abdominal hernia or a similar deformity or
disease and requires a truss to reduce the hernia.