Prosthetic appliances and services shall be authorized
under the Medi-Cal program when 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) Lower Limb
Prostheses:
(1) Shall be authorized when the
patient has a functional level of "one" or higher (potential for ambulation or
other functional activites). Lower limb prostheses shall not be authorized when
the patient has a functional level of "zero" (no potential for ambulation or
other functional activites).
(2)
Shall include all of the following:
(A)
Partial Foot Prostheses shall be authorized when the patient has had an
amputation of part or all of the foot and requires a definitive prosthesis to
permit ambulation or other functional activities.
(B) Ankle Prostheses shall be authorized when
the patient has had an amputation through or at the ankle, such as a Syme's
procedure and requires a definitive prosthesis to permit ambulation or other
functional activities.
(C) Below
Knee Prostheses shall be authorized when the patient has had an amputation
between the ankle and knee and requires an exoskeletal definitive prosthesis to
permit ambulation or other functional activities.
(D) Knee Disarticulation Prostheses shall be
authorized when the patient has had an amputation through or near the knee and
requires an exoskeletal definitive prosthesis to permit ambulation or other
functional activities.
(E) Above
Knee Prostheses shall be authorized when the patient has had an amputation
between the knee and hip and requires a definitive prosthesis to permit
ambulation or other functional activities.
(F) Hip Disarticulation Prostheses shall be
authorized when the patient has had an amputation through or near the hip and
requires an exoskeletal definitive prosthesis to permit ambulation or other
functional activities.
(G)
Hemipelvectomy Prostheses shall be authorized when the patient has had an
amputation with removal of half the pelvis and requires an exoskeletal
definitive prosthesis to permit ambulation or other functional
activities.
(H) Endoskeletal
Prostheses shall be authorized when the patient has had a lower limb amputation
and requires an endoskeletal definitive prosthesis to permit ambulation or
other functional activities, appropriate to the requested procedure
code(s).
(I) Immediate and Early
Post Surgical Procedures shall be authorized when the patient has had a lower
limb amputation and requires one or more of the following, appropriate to the
requested procedure code(s):
1. A temporary
prosthesis shall be authorized when it is applied soon after amputation before
the original amputation wound or residual limb revision(s) wound has completely
healed to permit some lower extremity function.
2. An additional cast change(s) and
realignment(s) of the temporary prosthesis specified in paragraph 1. above
shall be authorized when the patient has an existing or authorized temporary
prosthesis that requires these services.
3. A temporary application of a non-weight
bearing rigid dressing shall be authorized when it is applied soon after
amputation before the original amputation wound or the residual limb
revision(s) wound has completely healed, and when there is no expectation of
use of a prosthesis until the wound has completely healed.
(J) Initial Prostheses shall be authorized
when the patient has had a lower limb amputation that requires a temporary
prosthesis, and when the prosthesis is applied after the original amputation
wound or the residual limb revision(s) wound has healed but the residual limb
has not reached its final shape, appropriate to the requested procedure
code(s).
(K) Preparatory Prostheses
-- Below Knee shall be authorized when the patient has had a below-the-knee
amputation and requires a temporary prosthesis to permit some ambulation or
other functional activities in preparation for the fitting of a definitive
prosthesis, and when the prosthesis is applied after the original amputation
wound or the residual limb revision(s) wound has healed but the residual limb
has not reached its final shape.
(L) Preparatory Prostheses -- Above Knee
shall be authorized when the patient has had an above-the-knee amputation and
requires a temporary prosthesis to permit some ambulation or other functional
activities in preparation for the fitting of a definitive prosthesis, and when
the prosthesis is applied after the original amputation wound or the residual
limb revision(s) wound has healed but the residual limb has not reached its
final shape, appropriate to the requested procedure code(s).
(M) Additions to Lower Limb Prostheses:
1. Shall include all of the following:
a. Endoskeletal System -- Above
Knee.
b. Test Sockets.
c. Socket Variations.
d. Socket Inserts.
e. Suspension -- Below Knee.
f. Suspension -- Above Knee.
g. Exoskeletal Knee-Shin System.
h. Endoskeletal Knee-Shin System.
i. Miscellaneous.
2. 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 prosthesis, without
which the patient's medical need(s) would not be met.
c. The patient has an existing or authorized
lower limb prosthesis that is compatible with the
addition(s).
(N) Replacements -- Feet-Ankle Units shall be
authorized when both of the following criteria are met:
1. The cost(s) of the replacement is less
than the cost(s) of purchasing a new prosthesis.
2. The patient has an existing or authorized
lower limb prosthesis that is compatible with the
replacement(s).
(b) Upper Limb Prostheses shall include all
of the following:
(1) Partial Hand Prostheses
shall be authorized when the patient has had an amputation of part or all of
the hand and requires a definitive prosthesis to permit functional use of the
upper extremity, appropriate to the requested procedure code(s).
(2) Wrist Disarticulation Prostheses shall be
authorized when the patient has had an amputation through or near the wrist and
requires an exoskeletal definitive prosthesis to permit functional use of the
upper extremity.
(3) Elbow
Prostheses shall be authorized when the patient has had an amputation near the
elbow and requires an exoskeletal definitive prosthesis to permit functional
use of the upper extremity, appropriate to the requested procedure
code(s).
(4) Shoulder Prostheses
shall be authorized when the patient has had an amputation through or near the
shoulder and requires an exoskeletal definitive prosthesis to permit functional
use of the upper extremity.
(5)
Interscapular Thoracic Prostheses shall be authorized when the patient has had
an amputation with removal of both the shoulder joint and the scapula and
requires an exoskeletal definitive prosthesis to permit functional use of the
upper extremity.
(6) Immediate and
Early Post Surgical Procedures shall be authorized when the patient has had an
upper limb amputation and requires one or more of the following, appropriate to
the requested procedure code(s):
(A) A
temporary prosthesis shall be authorized when it is applied soon after
amputation before the original amputation wound or the residual limb
revision(s) wound has completely healed to permit some upper extremity
function.
(B) An additional cast
change(s) and realignment(s) of the temporary prosthesis specified in paragraph
(A) above shall be authorized when the patient has an existing or authorized
temporary prosthesis that requires these services.
(C) A temporary application of a non-weight
bearing rigid dressing shall be authorized when it is applied soon after
amputation before the original amputation wound or the residual limb
revision(s) wound has completely healed, and when there is no expectation of
use of a prosthesis until the wound has completely healed.
(7) Endoskeletal -- Elbow or Shoulder Area
Prostheses shall be authorized when the patient has had an upper extremity
amputation and requires a definitive prosthesis to permit functional use of the
upper extremity, appropriate to the requested procedure code(s).
(8) Endoskeletal -- Interscapular Thoracic
Prostheses shall be authorized when the patient has had an upper limb
amputation and requires a temporary or preparatory prosthesis to permit some
upper extremity function in preparation for the fitting of a definitive
prosthesis; and when the prosthesis is applied after the original amputation
wound or the residual limb revision(s) wound has healed but the residual limb
has not reached its final shape, appropriate to the requested procedure
code(s).
(9) Additions to Upper
Limb Prostheses 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 prosthesis, without which the
patient's medical need(s) would not be met.
(C) The patient has an existing or authorized
upper limb prosthesis that is compatible with the
addition(s).
(10)
Replacements for Upper Limb Prostheses shall be authorized when both of the
following criteria are met:
(A) The cost(s)
of the replacement is less than the cost(s) of purchasing a new
prosthesis.
(B) The patient has an
existing or authorized upper limb prosthesis that is compatible with the
replacement(s).
(c) Terminal Devices shall include all of the
following:
(1) Hooks shall include both the
base appliance or device and any required addition(s) or attachment(s) and
shall be authorized when one or both of the following criteria is met,
appropriate to the requested procedure code(s):
(A) For the requested base appliance or
device, both of the following criteria are met:
1. The patient requires a terminal device to
permit functional use of the upper extremity.
2. The patient has an existing or authorized
upper extremity prosthesis that is compatible with the terminal
device.
(B) For the
requested addition(s) or attachment(s), all of the following criteria are met:
1. The patient's medical condition requires
the specific function for which the addition(s) or attachment(s) was
designed.
2. The addition(s) or
attachment(s) is required by the patient to improve the functionality of the
terminal device, without which the patient's medical need(s) would not be
met.
3. The patient has an existing
or authorized terminal device that is compatible with the addition(s) or
attachment(s).
(2) Hands shall include both the base
appliance or device and any required addition(s) or attachment(s) 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 or device, both of the following criteria are met:
1. The patient requires a terminal device to
permit functional use of the upper extremity.
2. The patient has an existing or authorized
upper extremity prosthesis that is compatible with the terminal
device.
(B) For the
addition(s) or attachment(s), all of the following criteria are met:
1. The patient's medical condition requires
the specific function for which the addition(s) or attachment(s) was
designed.
2. The addition(s) or
attachment(s) is required to improve the functionality of the terminal device,
without which the patient's medical need(s) would not be met.
3. The patient has an existing or authorized
terminal device that is compatible with the addition(s) or
attachment(s).
(3) Hand Restoration Procedures shall include
casts, shading and measurements and shall be authorized when one or more of the
following criteria is met, appropriate to the requested procedure code(s):
(A) For the partial hand prosthesis, both of
the following criteria are met:
1. The patient
requires a partial hand prosthesis to permit functional use of the upper
extremity.
2. The patient has an
existing or authorized upper extremity prosthesis that is compatible with the
partial hand prosthesis.
(B) For the replacement glove(s), both of the
following criteria are met:
1. The patient
requires a replacement glove(s) for a hand prosthesis.
2. The patient has an existing or authorized
hand prosthesis that is compatible with the replacement
glove(s).
(d) External Power shall include all of the
following:
(1) Base Devices shall be
authorized when both of the following criteria are met:
(A) The patient requires an upper extremity
prosthesis with one or more electrically powered functional parts or electronic
circuitry that is activated by the patient to allow effective movement of the
upper extremity in the performance of activities of daily living and
instrumental activities of daily living, appropriate to the requested procedure
code(s).
(B) The patient is not
able to otherwise effectively use a manually operated
prosthesis.
(2) Terminal
Devices shall be authorized when all of the following criteria are met:
(A) The patient requires a terminal device
with one or more electrically powered functional parts or electronic circuitry
that is activated by the patient to allow effective movement of the upper
extremity in the performance of activities of daily living and instrumental
activities of daily living, appropriate to the requested procedure
code(s).
(B) The patient is not
able to otherwise effectively use a manually operated prosthesis.
(C) The patient has an existing or authorized
upper extremity prosthesis that is compatible with the terminal
device.
(3) Elbow
Attachments shall be authorized when all of the following criteria are met:
(A) The patient requires an elbow joint
attachment with one or more electrically powered functional parts or electronic
circuitry that is activated by the patient to allow effective movement of the
upper extremity in the performance of activities of daily living and
instrumental activities of daily living.
(B) The patient is not able to otherwise
effectively use a manually operated prosthesis.
(C) The patient has an existing or authorized
upper extremity prosthesis that is compatible with the elbow
attachment.
(4) Control
Modules and Battery Components shall be authorized when the patient has an
existing or authorized upper extremity electrically powered prosthesis that
requires a control module or battery component for functional use of the
prosthesis.
(e) Breast
Prostheses shall be authorized when the patient requires a prosthesis,
component or attachment to replace a breast(s) after surgical removal, to
support the surgical recovery or to hold the prosthesis in place.
(f) General Items shall include all of the
following:
(1) Prosthetic Socks shall be
authorized when both of the following criteria are met:
(A) The patient requires one or more of the
following appliances, appropriate to the requested procedure code(s):
1. A prosthetic sheath that is placed over a
residual limb and under a prosthetic sock while the prosthesis is being worn to
decrease the irritation of the residual limb.
2. A prosthetic sock that is worn between the
residual limb and the prosthesis to decrease the irritation of the residual
limb.
3. A prosthetic shrinker that
is worn over the residual limb to provide pressure against the residual limb to
decrease accumulation of fluid in the residual limb.
4. A thinly woven sock that is used over the
residual limb during the fitting of a prosthesis.
(B) The patient has an existing or authorized
lower extremity prosthesis that is compatible with the prosthetic sheath, sock
or shrinker.
(2) Repairs
for Prosthetic Appliances shall include repairs, maintenance, replacements and
associated labor and shall be authorized when all of the following criteria are
met:
(A) The patient has an existing
prosthesis that requires repair, maintenance or replacement.
(B) The repair, maintenance or replacement
cost(s), including the associated labor is less than the cost(s) of purchasing
a new prosthetic appliance.
(C) 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.
(g) Miscellaneous Prosthetic Appliances shall
be authorized when the patient has had an amputation or removal of a body part
and requires one or more of the following appliances or devices, appropriate to
the requested procedure code(s):
(1) A
prosthetic appliance or service that is not functionally equivalent to, or does
not meet the descriptor for, an existing prosthetic appliance or service
procedure code(s).
(2) A device to
enable speaking in the absence of the larynx.
(3) A device to enable speaking with a
tracheostomy.
(4) A replacement
battery or accessory for an artificial larynx.
(5) A trachea-esophageal voice
prosthesis.
(6) A voice
amplifier.