Orthotic and Prosthetic Services Mandate Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 11|02|2006 POLICY LAST UPDATED: 10|06|2021

OVERVIEW This is an administrative policy to document the state-mandated coverage guidelines for orthotic and prosthetic services (§ 27-20-52, full text below).

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Prior authorization review is not required.

POLICY STATEMENT Medicare Advantage Plans and Commercial Products Orthotic and prosthetic services are a covered benefit for Medicare Advantage Plans and Commercial Products.

EXCEPTION: Corrective or orthopedic shoes and orthotic devices used in connection with footwear are NOT covered unless for the treatment of diabetes.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable Medical Equipment, Medical Supplies, and Prosthetic Devices coverage/benefits.

BACKGROUND §27-20-52 Reimbursement for orthotics and prosthetic services. (a) As used in this section:

(1) "Federal reimbursement rates" means the current listed fee schedule from the Centers for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding system (HCPCS) and the corresponding reimbursement rates.

(2) "Orthosis" means a custom fabricated brace or support that is designed based on medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as defined in this section, or any of the following assistive technology devices: commercially available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses; upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other similar devices as determined by the director of the department of health, such as those commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply facility.

(3) "Orthotics" means the science and practice of evaluating measuring, designing, fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The Medical Coverage Policy | Orthotic and Prosthetic Services Mandate d

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

practice of orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and postural analysis, orthotists assess and design orthoses to maximize function and provide not only the support but the alignment necessary to either prevent or correct a deformity or to improve the safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit and function of the orthotic device by periodic evaluation.

(4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity applications capable of weight bearing. Prosthesis means an artificial medical device that is not surgically implanted and that is used to replace a missing limb, appendage, or other external human body part including an artificial limb, hand, or foot. The term does not include artificial eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

(5) "Prosthetics" means the science and practice of evaluation, measuring, designing, fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial training necessary to accomplish the fitting of, a prosthesis through the replacement of external parts of a human body lost due to amputation or congenital deformities or absences. The practice of prosthetics also includes the generation of an image, form, or mold that replicates the patient's body or body segment and that requires rectification of dimensions, contours and volumes for use in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an artificial appendage that is designed either to support body weight or to improve or restore function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis and clinical assessment of the requirements necessary to refine and mechanically fix the relative position of various parts of the prosthesis to maximize function, stability, and safety of the patient. The practice of prosthetics includes providing and continuing patient care in order to assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of the prosthetic device by periodic evaluation.

(6) "Private insurance company" means any insurance company, or management company hired by an insurance company, who is any of the following:

(i) based in the state of Rhode Island; or (ii) provides coverage for citizens for the state of Rhode Island; or
(iii) allows subscribing patients to seek prosthetic or orthotic services in the state of Rhode Island.

(b) Every individual or group health insurance contract, plan or policy delivered, issued for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage that includes coverage for physician services in a physician's office and every policy, which provides major medical or similar comprehensive type coverage shall provide coverage for benefits for orthotic and prosthetic devices that equal those benefits provided for under federal laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951 and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

(c) A health insurance contract, plan or policy may require prior authorization for orthotic and prosthetic devices in the same manner that prior authorization is required for any other covered benefit.

(d) Covered benefits for orthotic or prosthetic devices shall be limited to the most appropriate model that adequately meets the medical needs of the patient as determined by the insured's treating physician.

(e) The repair and replacement of orthotic or prosthetic devices also shall be covered subject to co-payments and deductibles, unless necessitated by misuse or loss.

(f) An insurer may require, if coverage is provided through a managed care plan, that benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

CODING Not applicable

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

RELATED POLICIES Not applicable

PUBLISHED Provider Update, December 2021 Provider Update, September 2019 Provider Update, April 2018 Provider Update, June 2017 Provider Update, May 2016

REFERENCES RIGL Mandate 27-20-52. Accessed on 10/1/2021: http://www.rilin.state.ri.us/statutes/title27/27-20/27-20- 52.HTM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS