Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom MHCP is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Orthotic and prosthetic devices are covered for all eligible MHCP members.

Covered Services

Minnesota Health Care Programs (MHCP) covers orthotic and prosthetic devices, supplies, and services that are medically necessary and prescribed by a physician or licensed health care prescriber who has authority in Minnesota to prescribe orthoses and prostheses, including devices customized to the member’s needs. MHCP covers an additional orthotic and prosthetic device for all MHCP members for purposes of bathing or showering. For eligible members, MHCP also covers an orthotic and prosthetic device for purposes of performing physical activities including, but not limited to, running, biking, swimming, and maximizing the enrollee’s limb function. Devices for purposes of bathing or showering do not require prior authorization unless the member already has devices for both everyday use and recreation. Prior authorization is required for devices for recreational purposes.

Spinal Orthoses

Codes: L0112-L1499
An orthotic for the spine is considered medically necessary to:

· Facilitate healing of the spine or related soft tissues

· Reduce pain by restricting mobility

· Support weak spinal muscles or a deformed spine

· Treat scoliosis

Orthotics for the spine are covered without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge is more than $400.

Hip Orthoses

Codes: L1600-L1755, L2040-L2090
An orthotic for the hip is considered medically necessary to:

· Stabilize the hip

· Correct and maintain hip abduction

One orthotic for the hip is covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the second or subsequent orthotic for the hip in any calendar year.

Lower Limb Orthoses

Codes: L1810-L2035, L2106-L2999, L4350-L4631
A lower limb orthotic is considered medically necessary to:

· Treat contractures

· Immobilize a limb to promote healing

· Provide support and stability during ambulation

Four lower limb orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the third or subsequent set of lower limb orthotics in any calendar year.

Upper Limb Orthoses

Codes: L3650-L3999
An upper extremity orthotic is considered medically necessary to:

· Immobilize an extremity to promote healing

· Treat contractures

· Provide support and stability during activities of daily living

Four upper extremity orthotics (two sets of bilateral orthotics) are covered per calendar year without authorization when medically necessary with the following exceptions:

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· Authorization is required for the third or subsequent set of upper extremity orthotics in any calendar year.

Lower Limb Prosthetics

Codes: L5000-L5999
Evaluation and Management
Evaluation of the member’s functional ability is required. For members with existing prostheses, for whom a similar replacement is requested, evaluation can be based on the member’s history and current condition. For members for whom a first prosthesis is requested or for whom a significantly different prosthetic is requested, evaluation must be based on clinical observation.

Evaluations must be performed by a professional certified by the American Board of Certification in Orthotics and Prosthetics, or the Board of Certification in Orthotics and Prosthetics or a professional who has similar training or expertise.

Medical records must include:

· Reason for amputation

· Date of amputation

· Status of current limb

· Description of prosthetic being provided

· Which activities of daily living are affected and how they are impacted

· Functional capabilities before and after amputation

· Functional level (level 0-4)

Use the following functional levels in the evaluation. Provide specific information about the member’s ambulation history, performance, and activities of daily living to support assignment of an individual to a functional level.

· Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.

· The individual does not have sufficient cognitive ability to safely use a prosthesis with or without assistance.

· The individual requires assistance from equipment or a caregiver to transfer and use of a prosthesis does not improve mobility or independence with transfers.

· The individual is wheelchair dependent for mobility and use of a prosthesis does not improve transfer abilities.

· The individual is bedridden and has no need or capacity to ambulate or transfer.

· Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator.

· The individual has sufficient cognitive ability to safely use a prosthesis with or without an assistive device or the assistance or supervision of one person.

· The individual is capable of safe but limited ambulation within the home or on a similar flat surface like a home, with or without an assistive device or with or without the assistance or supervision of one person.

· The individual requires the use of a wheelchair for most activities outside of their residence.

· The individual is not capable of most of the functional activities designated in Level 2.

· Level 2: Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. This level is typical of the limited community ambulator.

· The individual can, with or without an assistive device (which may include one or two handrails) and/or with or without the assistance or supervision of one person:

· Perform the Level 1 tasks listed in this manual section

· Ambulate on a flat, smooth surface (for example, concrete, asphalt) such as might be found outside the home (for example, porch, deck, patio garage, driveway).

· Negotiate a curb.

· Access public or private transportation.

· Negotiate 1-2 stairs.

· Negotiate a ramp built to ADA specifications.

· The individual may require a wheelchair for distances that are beyond the perimeters of the yard or driveway, apartment building, etc.

· The individual is only able to increase their generally observed speed of walking for short distances or with great effort.

· The individual is generally not capable of accomplishing most of the tasks at Level 3 (or does so infrequently with great effort).

· Level 3: Has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

· With or without an assistive device (which may include one or two handrails), the individual is independently capable (that is, requires no personal assistance or supervision) of performing the Level 2 tasks listed in this manual section and can:

· Walk on terrain that varies in texture and level (for example, grass, gravel, uneven concrete).

· Negotiate 3-7 consecutive stairs.

· Walk up/down ramps built to ADA specifications.

· Open and close doors.

· Ambulate through a crowded area (for example, grocery store, big box store, restaurant).

· Cross a controlled intersection within their community within the time limit provided (varies by location).

· Access public or private transportation.

· Perform dual ambulation tasks (for example, carry an item or meaningfully converse while ambulating).

· The individual does not perform the activities of Level 4.

· Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels typical of the prosthetic demands of the child, active adult, or athlete.

· With or without an assistive device (which may include one or two handrails), this individual is independently capable (that is, requires no personal assistance or supervision) or performing high-impact domestic, vocational, or recreational activities such as:

· Running

· Repetitive stair climbing

· Climbing of steep hills

· Being a caregiver for another individual

· Home maintenance (for example, repairs, cleaning)

Feet and Ankles

· A power-assist ankle-foot or ankle system (L5969) or multiaxial ankle with swing-phase active dorsiflexion feature (L5968) may be medically necessary for members whose functional level is 3 or above.

· An external keel SACH foot (L5970) or single-axis ankle or foot (L5974) may be medically necessary for members whose functional level is 1 or above.

· A flexible-keel foot (L5972) or multi-axial ankle/foot (L5978) may be medically necessary for members whose functional level is 2 or above.

· A microprocessor-controlled ankle foot system (L5973), energy-storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex-foot system (L5980), flex-walk system of equal (L5981), or shank-foot system with vertical loading pylon (L5987) may be medically necessary for members when one of the following criteria is met:

· The member’s functional level is 3 or above; or,

· The member’s functional level is 2; and,

· Meets the functional level 2 coverage criteria for a fluid, pneumatic, or electronic/microprocessor control addition for a prosthetic knee; and,

· A higher-level (that is, functional level 3) foot is required for the safe and proper use of the prescribed knee system.

· An axial rotation ankle unit (L5982-L5986) may be medically necessary for members whose functional level is 2 or above.

Knees

· A fluid or pneumatic knee unit (L5610, L5613, L5614, L5615, L5722-L5780, L5814, L5822-L5841) or control addition, fluid (L5848), or electronic/microprocessor (L5856-L5858) may be medically necessary for members whose functional level is 3 or above.

· The member has had a clinical evaluation to determine their functional level; and,

· Documentation in the medical record outlines the rationale for selection of a fluid, pneumatic, or electronic/microprocessor-controlled knee, including how the selected knee will:

· Improve the member’s functional health outcomes (for example, fall-reduction, injury prevention, lower energy expenditure); and,

· Help the member accomplish their ADLs; and,

· Lower-level knee systems (for example, knee systems which exclude use of fluid, pneumatic, or microprocessor) have been considered and ruled out based on the member’s specific functional and medical needs.

· An electronic/microprocessor-controlled knee system (L5856, L5857, or L5858 plus associated components) may be medically necessary for member whose functional level is 2 or above when all of the following criteria are met:

· The electronic/microprocessor knee is indicated for functional level 2; and,

· The electronic/microprocessor knee has integrated technology that allows the knee to detect when the user trips or stumbles and can automatically adjust to stabilize the knee unit (for example, stumble recovery); and,

· The member is able to make use of a product that requires daily charging; and,

· The member is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

· A knee with powered and programmable flexion/extension assist control (L5859) may be medically necessary for members when all of the following criteria are met:

· The member has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee; and,

· The member has a functional level of K3; and,

· The member has a comorbidity of the spine or sound limb affecting hip extension or quadriceps function that impairs K3 level function with the use of a microprocessor-controlled knee alone; and,

· The member is able to make use of a product that requires daily charging; and,

· The member is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

· A high-activity knee control frame (L5930) may be medically necessary for members whose functional level is 3 or above, or for members whose weight requires the increased strength of this kind of frame.

· Other knee systems (L5611, L5616, L5710-L5718, L5810-L5818) may be medically necessary for members whose functional level is 1 or above.

Hip
A pneumatic or hydraulic polycentric hip joint (L5961) may be medically necessary for highly motivated members whose functional level is 2 or above.

Additional Criteria
Vacuum suspension system (L5781 or L5782) may be medically necessary for functional level 2 and above.

Devices for Bathing or Recreation

Orthotic and prosthetic devices for purposes of bathing or showering and for purposes of recreation are covered. Devices for both bathing and recreation are covered per five years. Members cannot automatically obtain a new device if the original is still in working order. Members whose functional level is 2 or above are eligible for recreational prosthetics. Authorization is required for devices for recreation. Use modifier U2 for billing. Authorization is not required for devices for bathing or showering. Use modifier U1 for billing. While devices for bathing or showering do not require authorization, if a member has devices for everyday use and for recreation, then authorization is required for a bathing device. It is the expectation of MHCP that devices for bathing or showering are made from the least costly and waterproof materials.

Repairs and Replacements

Codes: L4000-L4210, L7510-L7520
Repairs to orthotic devices are covered without authorization with the following exceptions:

· Repairs to an orthotic require authorization if the submitted charge for any line using modifier RB is more than $400.

· HCPCS codes without an MHCP fee schedule rate always require authorization if the submitted charge is more than $400.

Replacements for a device or parts of a device are covered, without regard to useful lifetime restrictions, if ordered by an eligible provider because:

· Of a change in the physiological condition of the enrollee;

· Of an irreparable change in the condition of the device or in a part of the device; or

· The condition of the device or in a part of the device requires repairs and the cost of the repairs would be more than 60 percent of the cost of a replacement device or of the part being replaced.

Confirmation from a provider is required if the device or part being replaced is less than three years old.

Cranial Remolding Orthoses

Code: S1040
A cranial remolding orthotic is considered medically necessary for treatment of head deformities associated with:

· Premature birth

· Restrictive intrauterine positioning

· Torticollis

· “Back to Sleep” sleeping positions

Up to two cranial remolding orthotics are covered without authorization for members under age 2. Authorization is required for the third and subsequent cranial remolding orthotic.

Scalp Hair Prostheses

Code: A9282
Scalp hair prostheses are considered medically necessary for treatment of medical conditions that result in hair loss. Coverage is limited to $1,000 per calendar year.

Implantation of Iris Prosthesis

Codes: 66683 (implantation of iris prosthesis) and C1839 (iris prosthesis)
The implantation of an iris prosthesis is considered medically necessary for treatment of aniridia for members three years of age and older. Authorization is always required. Not covered for members with certain eye conditions, such as uncontrolled inflammation, severe chronic uveitis, microphthalmos, untreated retinal detachment, untreated chronic glaucoma, rubella cataract, rubeosis of the iris, proliferative diabetic retinopathy, Stargardt’s retinopathy, or intraocular infections, or in pregnant women.

Noncovered Services

· An orthotic or prosthetic device for which Medicare has denied the claim as not medically necessary.

· A device that does not meet criteria as indicated in this policy is considered not medically necessary.

· A device whose primary purpose is to serve as a convenience to a person caring for the member.

· A device that serves to address social and environmental factors and that does not directly address the member’s physical or mental health.

· A device that is supplied to the member by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device.

· Repair costs for an orthotic or prosthetic device that is under warranty.

· Repair costs for any rental equipment.

· Lower limb prosthetics for a member whose functional level is 0 are considered not medically necessary.

· Orthotics when used to prevent injury in a previously uninjured limb.

· A custom-fabricated device when the member’s needs can be met with a prefabricated device.

· Additions or components that are not required for the effective use of the device or do not serve a functional purpose are considered not medically necessary.

· Additions provided for cosmetic reasons are considered not medically necessary.

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Authorization

Authorization is required for the following:

· Quantities over MHCP quantity limits.

· Repairs and replacements to any device if the submitted charge for any line using modifier RB is more than $400.

· All unlisted or unspecified services, including any repairs to devices.

· All HCPCS codes on the MHCP fee schedule that indicate prior authorization is always required.

· Devices for recreational purposes.

· Third orthotic or prosthetic device of any type.

· While devices for bathing or showering do not require authorization, if a member has a device for everyday use and for recreation, then authorization is required for a bathing device.

· All microprocessor products, including the following HCPCS codes: L2006, L5856, L5857, L5858, L5973, L6882, L7180, L7181, L8701, and L8702.

· The following HCPCS codes if the submitted charge is more than $400: L0452, L0624, L0629, L0634, L0999, L1001, L1499, L2861, L2999, L3649, L3677, L3891, L3956, L3999, L4210, L5999, L7499, L8499, or L9900.

· More than two test sockets (L5618, L5620, L5622, L5624, L5626, L5628) for an individual prosthesis are not reasonable and necessary unless there is documentation in the medical record which justifies the need. Authorization is required for third or subsequent test sockets.

Authorization is not required for immediate postsurgical or early fittings (L5400-L5460), initial prostheses (L5500-L5505), preparatory prostheses (L5510-L5600), or the first two test sockets (L5618, L5620, L5622, L5624, L5626, L5628).

Submit authorization requests through MN–ITS (Authorization Request 278). Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the medical review agent. Write the MN–ITS Authorization Request number on each page of each document. Review the Authorization section of the MHCP Provider Manual for more information about authorization requests.

· Submit the base HCPCS code with appropriate modifiers on the first line of the authorization request if a new device is being requested.

· List all add-on items on separate lines on the authorization request. List each item by HCPCS code with appropriate modifiers, quantity, and submitted charge.

· Do not list items on an authorization request when the item never requires authorization. These items should be billed on a separate claim.

· If requesting authorization for quantities over the annual limit, document why the additional item is required, and how the requested item meets the member’s medical and functional needs.

· If requesting authorization because MHCP does not have a fee schedule rate, include pricing documentation. For prefabricated devices, submit an invoice or manufacturer’s suggested retail price (MSRP) list. For custom-fabricated devices, submit documentation of labor (in minutes) and invoices for materials.

· If requesting authorization for repairs, document that the repair can reasonably be expected to delay replacement by at least one year.

· MHCP will not authorize more units per line than are allowed by Medicare’s Medically Unlikely edits (MUEs). When requesting authorization for bilateral devices where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT as appropriate. Documentation must clearly establish that the greater number of units is required.

· When multiple items that are different but require the same miscellaneous code are requested, each item must be listed on a separate line of the authorization request. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or a narrative description up to 20 characters.

· Documentation for purchase must include:

· Member’s medical and functional needs, and how the requested device meets those needs.

· Assessment of the member’s functional status and how the member’s functional status relates to the need for the requested items.

· Consideration of less costly alternatives and why alternative devices do not meet the member’s needs.

· When requesting authorization for a device for bathing or showering as a recipient’s third device, include documentation explaining why the recipient’s other devices do not suffice for bathing or showering.

· When requesting authorization for identical replacement of components on an existing device, it is not necessary to establish medical necessity for those components. Documentation that the component needs to be replaced and is not covered by a warranty.

· When requesting authorization for non-identical replacement of components on an existing device, document the medical necessity for the requested components.

· Each line will be approved or denied, with the allowed amount listed, if approved.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics for general billing information.

Bill orthotic and prosthetic devices using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS User Manual for claim instructions.

· If the member has Medicare, MHCP will pay only the deductible or coinsurance on any item for which Medicare made payment, regardless of any MHCP authorization.

· Shipping, delivery, or setup costs are included in the MHCP maximum allowable payment and may not be separately billed to MHCP or the member.

· MHCP will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When billing for bilateral devices where more units are required than are allowed by the MUEs, the units must be on different lines, with modifiers NU RT and NU LT as appropriate.

· Use modifier U1 on L HCPCS codes for devices for bathing or showering purposes.

· Use modifier U2 on L HCPCS codes for devices for recreational purposes.

· When billing for labor for repairs, specify the number of units and the hourly rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.

· When billing repairs use modifier RB and the HCPCS code of the item being repaired.

· When billing for items approved on an authorization, submit one claim for all approved lines, ensuring the HCPCS codes, modifiers, and descriptions on the claim match the same information on the authorization.

· Enter the authorization number in the Authorization field for each line.

· Bill items without an authorization on a separate claim.

· When the Model Number field is used, do not use the Notes field on the Services tab in MN–ITS. Use the Claim Notes field on the Claim Information tab.

· Submit the usual and customary charge for each line, not the approved amount from the authorization letter. Payment will be the balance of the lesser of the billed amount or the approved amount after any primary or secondary payers have made the payment.

Definitions

Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.

Custom-fabricated: Item that is made for a specific member from his or her individual measurements or pattern, starting with basic materials such as plastic, metal, leather, etc.

Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body part or for restricting or eliminating motion in a diseased or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded A4466.

Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.

Prefabricated: Item that is not made for a specific member’s specifications. They may be adjusted or altered to meet the member’s needs but are not made specifically for the member. An item that is assembled solely from prefabricated components is considered prefabricated.

Prosthetic: A device that is used for the purpose of replacing missing limbs to help individuals regain functionality and independence.

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