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MP 1.04.01

Prosthetics


Section
Durable Medical Equipment
Original Policy Date
11/30/96

Last Review Status/Date
Reviewed by consensus/1:2004

Issue
2:2004
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Prosthetics are artificial substitutes that replace all or part of a body organ, or replace all or part of the function of a permanently inoperative, absent, or malfunctioning body part.


Policy

Prosthetic appliances are considered medically necessary when prescribed by a qualified provider to replace absent or nonfunctioning parts of the human body by an artificial substitute, whether surgically implanted or worn as an anatomic supplement.

 

Prosthetic appliances include but are not limited to:

Surgical Prostheses

  • artificial joints necessary for joint repair and reconstructive surgery;
  • breasts, internal and external (including a surgical brassiere), for post-mastectomy reconstruction;
  • cardiac pacemakers, atomic or electronic;
  • cochlear implants;
  • intra-ocular lenses;
  • maxillofacial and intra-ocular lenses as replacement of either surgically removed or congenitally absent crystalline lenses of the eye;
  • penile prostheses in men suffering impotency resulting from disease or injury;
  • urethral sphincters for urinary incontinence.

Nonsurgical Prostheses:

  • artificial eyes;
  • artificial limbs replacing all or part of absent extremities;
  • speech aids;
  • urinary collection and retention systems (Foley catheters, tubes, bags, etc.) in cases of permanent urinary incontinence.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

Surgical prostheses are covered under the Surgery Benefit, whereas nonsurgical prostheses are covered under the Durable Medical Equipment Benefit.

 

Coverage should include supplies necessary for the effective use of a covered prosthetic appliance (e.g., batteries needed to operate an artificial larynx, harnesses, and stump socks essential to use of an artificial limb), as well as adjustment, repairs, and replacement of the device.

Shoes (pair) when either one or both shoes are an integral part of the artificial limb(s) should be considered covered services.

 

Adjustments and repair of the device(s) are covered when they are necessary to make equipment serviceable for as long as the equipment continues to be medically required.

Replacement is provided for devices only after their normal life span (wear and tear) has made them ineffective, if the device malfunctions, and/or for size adjustments.

 

The following are often excluded by Plan contract language:

  • Dentures replacing teeth or structures directly supporting teeth;
  • Electrical continence aids, either anal or urethral;
  • Hairpieces for male-pattern alopecia;
  • Hearing aids;
  • Implants for cosmetic purposes; and
  • Penile prostheses for psychogenic impotence.


Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1990 through December 1995. The search strategy focused on references containing the following Medical Subject Headings:

 

Research was limited to English-language journals on humans.

 

Codes

Number

Description

CPT    Code applicable prosthetic 
ICD-9 Procedure    Code appropriate “Insertion” codes 
ICD-9 Diagnosis    Code appropriate condition 
HCPCS  L5000–L9999  Prosthetics code range 
Type of Service  Durable Medical Equipment 
Place of Service  Inpatient
 
Outpatient
 


Index

Appliances, Prosthetic
Prosthetic Appliances


Policy History

Date Action Reason
11/30/96 Add to Durable Medical Equipment section New policy
7/12/02 Replace policy Policy reviewed without literature review; new review date only
04/16/04 Replace policy Policy reviewed by consensus; no further review scheduled


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