Orthotics and Prosthetics
Overview
Orthotic and prosthetic devices are used to support weak body parts, replace body parts, or restore ambulation. Orthoses support weak body parts and are considered medically necessary for the treatment of musculoskeletal deformity or injury, neuromuscular disorders, and chronic pain. Prostheses replace body parts or restore ambulation and are considered medically necessary for the treatment of amputation or congenital birth defect impacting a limb.
Eligible Providers
The following providers may provide orthotics and prosthetics:
TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (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 Medical Assistance and MinnesotaCare members.
Covered Services
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 everyday needs. Members must be appropriately examined, fitted, and trained by an orthotist or prosthetist before using their device and requesting authorization, if applicable. MHCP covers an additional device for all members for purposes of bathing or showering. For eligible members, MHCP also covers a recreational device for purposes of performing physical activities including, but not limited to, running, biking, swimming, and maximizing the member’s limb function.
When providing orthotics and prosthetics, providers must:
Orthoses
Evaluation and Management
Evaluation of the member’s condition and functional ability is required. For members with existing orthoses, 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 orthosis is requested or for whom a significantly different orthotic 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. Document the evaluation. The evaluation must be less than 180 days old.
Medical records must include:
Use the following categories for orthotics for the spine, hip, and extremities when evaluating the member: prefabricated, custom fitted, or custom fabricated. Provide specific information about the member’s condition and the type of orthotic.
Prefabricated or off-the-shelf (OTS) orthoses are devices that are prefabricated. These devices require minimal self-adjustment. Minimal self-adjustment refers to adjustments that may be made by the member or their caregiver. These devices do not involve bending, molding, trimming, or altering beyond minimal self-adjustment. Prefabricated orthoses do not require expertise of a certified orthotist or professional who has similar training or expertise.
Custom fitted orthoses are devices that are prefabricated. These devices require modification of the prefabricated item to provide a customized fit. Custom fitted orthoses may or may not be supplied with a kit that requires assembly. Assembly of the device or installation of components in preparation of the device does not change classification from OTS to custom fitted. Classification as custom fitted requires substantial modification. Modifications must involve bending, molding, trimming, or altering beyond minimal self-adjustment. Suppliers must document the customizations of the device.
Custom fabricated orthoses are devices that are individually made for a specific member. These devices require substantial customization from castings, measurements, tracings, and imaging of the body part. Custom fabricated orthoses may involve calculations, components, and templates. Materials required may include cloth, leather, metal, plastic, and other raw materials for construction of the device. Classification as custom fabricated requires substantial modification including bending, cutting, drilling, molding, sewing, and vacuum forming the device to the member. This fitting requires expertise of a certified orthotist or professional who has similar training or expertise.
MHCP covers orthoses for the spine, hip, lower and upper limbs, cranial remolding orthoses, protective helmets, and orthopedic and therapeutic footwear. There is no separate payment for the evaluation, fitting, molding, or training of use for equipment as these services are included in the applicable HCPCS codes. The usual reasonable useful lifetime (RUL) of five years for durable medical equipment (DME) does not apply to custom fitted or custom fabricated orthotics. Refer to the Reasonable Useful Lifetime subsection of this MHCP Provider Manual section for information on subsequent new or replacement custom orthotics.
Authorization is not required for custom orthotic devices for everyday use and for purposes of bathing or showering, unless the individual HCPCS codes always require authorization. Authorization is required for recreational orthotics and subsequent new custom orthotics if the current orthotic is less than three years old. Refer to the Devices for Bathing or Recreation subsection of his MHCP Provider Manual section for information on devices for purposes of bathing or showering or recreation.
Spinal Orthoses
Codes: L0112-L1499
Orthotics for the spine are considered medically necessary to:
MHCP covers one unit of prefabricated orthotics for the spine for purposes of everyday use and for bathing per calendar year without authorization. MHCP covers one custom orthotic device for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities of prefabricated orthotics, and subsequent new custom orthotics if the current orthotic is less than three years old.
Types of orthotics for the spine include cervical orthotics, thoracic-lumbar-sacral orthotics (TLSOs), sacral orthotics (SOs), lumbar orthotics (LOs), lumbar-sacral orthotics (LSOs), cervical-thoracic-lumbar-sacral orthotics (CTLSOs), cervical halo procedures, scoliosis orthotic devices, accessories, and additions.
Hip Orthoses
Codes: L1600-L1755, L2040-L2090
Orthotics for the hip are considered medically necessary to:
MHCP covers one unit of prefabricated orthotics for the hip for purposes of everyday use and for bathing per calendar year without authorization. MHCP covers one custom orthotic device for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities of prefabricated orthotics, and subsequent new custom orthotics if the current orthotic is less than three years old.
Types of orthotics for the hip include hip orthotics (HOs), Legg Perthes orthotics, and hip-knee-ankle-foot orthotics (HFAKOs).
Lower Limb Orthoses
Codes: L1810-L2038, L2106-L2999, L4350-L4631
Lower limb orthotics are considered medically necessary to:
MHCP covers two units of prefabricated orthotics per each impacted extremity per type of orthotic for purposes of everyday use and one unit for bathing per calendar year without authorization. MHCP covers one custom orthotic device per each impacted extremity per type of orthotic for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities of prefabricated orthotics, and subsequent new custom orthotics if the current orthotic is less than three years old.
Types of orthotics for the lower limb include knee orthotics (KOs), ankle-foot orthotics (AFOs), knee-ankle-foot orthotics (KAFOs), accessories, and additions. Documentation must include physician order and medical necessity for each type of orthotic dispensed.
Custom-fabricated swing-phase release and microprocessor-controlled KAFOs (L2005, L2006)
Custom-fabricated KAFOs with automatic lock and swing-phase release (L2005) and microprocessor-controlled KAFOs (L2006) are covered with authorization if all of the following criteria are met:
Upper Limb Orthoses
Codes: L3650-L3999, L8701, L8702
Upper limb orthotics are considered medically necessary to:
MHCP covers two units of prefabricated orthotics per each impacted extremity per type of orthotic for purposes of everyday use and one unit for bathing per calendar year without authorization. MHCP covers one custom orthotic device per each impacted extremity per type of orthotic for purposes of everyday use and for bathing without authorization. Authorization is required for recreational orthotics, excess quantities of prefabricated orthotics, and subsequent new custom orthotics if the current orthotic is less than three years old.
Types of orthotics for the upper limb include shoulder orthotics (SOs), elbow orthotics (EOs), finger orthotics (FOs), elbow-wrist-hand orthotics (EWOs), wrist-hand-finger orthotics (WHFOs), wrist-hand orthotics (WHOs), shoulder-elbow-wrist-hand-finger orthotics (SEWHFOs), accessories, and additions. Documentation must include physician order and medical necessity for each type of orthotic dispensed.
Cranial Remolding Orthoses
Code: S1040
Cranial remolding orthotics are considered medically necessary for treatment of head deformities associated with:
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.
Protective Helmets
Codes: A8000-A8004
Protective helmets, including prefabricated and custom fabricated items and soft interface replacements, are considered medically necessary for members at risk of head injury due to a medical condition such as seizures or developmental disability. Most members older than 2 years old can be served with one protective helmet per year. Members younger than 2 years old may require more frequent replacements. Documentation needs to explain why a prefabricated helmet does not suffice.
Orthopedic and Therapeutic Footwear
Codes: A5500-A5501, A5503-A5507, A5510-A5513, A9283, L3000-L3595, L3600-L3649
Orthopedic footwear is considered medically necessary for treatment of structural conditions of the foot. Therapeutic footwear is considered medically necessary to prevent diabetic ulcers.
Orthopedic Footwear
Custom-made orthopedic shoes, modifications, additions, and inserts are considered medically necessary when the shoes are an integral part of the leg brace, or the member has one or more of the following:
MHCP covers two units each of orthopedic shoes and inserts per each impacted extremity per calendar year without authorization. Deluxe features of orthopedic shoes (A5508) are noncovered.
Orthopedic shoes, modifications, additions, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts. All items must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist, or prosthetist.
Therapeutic Shoes and Inserts for Diabetes
Custom-made or prefabricated therapeutic shoes, modifications, and inserts are considered medically necessary for members with diabetes and one or more of the following:
MHCP covers two units of therapeutic shoes and three units of inserts per each impacted extremity per calendar year without authorization. The member’s medical condition may impact one foot or both feet. Inserts are only covered for member-owned therapeutic shoes.
Therapeutic shoes, modifications, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of diabetic shoes and inserts. All items must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist, or prosthetist.
Foot Pressure Off-Loading Devices
Foot pressure off-loading devices are considered medically necessary for members with existing pressure ulcers of the foot.
Prostheses
Evaluation and Management
Evaluation of the member’s condition and 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. Document the evaluation. The evaluation must be less than 180 days old.
Medical records must include:
MHCP covers prostheses for the lower and upper limbs, breasts, eyes, face, and medical wigs. There is no separate payment for the evaluation, fitting, molding, or training of use for equipment as these services are included in the applicable HCPCS codes. The usual RUL of five years for DME does not apply to prosthetics. Refer to the Reasonable Useful Lifetime subsection of this MHCP Provider Manual section for information on subsequent new or replacement prosthetics.
Authorization is not required for initial prosthetic devices for everyday use and for purposes of bathing or showering or for bilateral amputees, unless the individual HCPCS codes always require authorization. Authorization is required for recreational prosthetics and subsequent new prosthetics for any purpose. Refer to the Devices for Bathing or Recreation subsection of his MHCP Provider Manual section for information on devices for purposes of bathing or showering or recreation.
MHCP covers prosthetic sheaths (L8400, L8410, L8415, L8417), shrinkers (L8440, L8460, L8465), and socks (L8420, L8430, L8435, L8470, L8480, L8485) for member-owned devices.
Lower Limb Prostheses
Codes: L5000-L5999
Lower limb prosthetics are considered medically necessary for treatment of amputation or congenital birth defects in lower extremities.
Medical records must include:
Use the following functional levels in the evaluation. Provide specific information about the member’s ambulation history, performance, and ADLs to support assignment of a member to a functional level.
Members whose function level is 0 are not eligible for lower limb prosthetics as the device would not enhance mobility or quality of life.
Feet and Ankles
Knees
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.
Upper Limb Prostheses
Codes: L6000-L7259, L7400-L7499, L8400-L8499
Upper limb prosthetics are considered medically necessary for treatment of amputation or congenital birth defects in upper extremities.
Medical records must include:
Use the following categories for upper limb prosthetics when evaluating the member. Provide specific information about the member’s ambulation history, performance, and ADLs to support assignment of a particular device.
Passive Prostheses
Passive prostheses do not move on their own, are lightweight, and enhance the member’s condition by stabilizing or carrying objects. A passive upper extremity prosthetic is covered for members if all of the following criteria are met:
Body-Powered Prostheses
Body-powered prostheses use body movements to control the device. A body-powered upper extremity prosthetic is covered for members if all of the following criteria are met:
Myoelectric or Hybrid Prostheses
Myoelectric prostheses use electromyographic signals in muscle contractions to control the device. A myoelectric or hybrid upper extremity prosthetic is covered for members if all of the following criteria are met:
Breast Prostheses
Codes: L8000-L8002, L8010, L8015, L8020, L8030-L8033, L8035, L8039
Breast prosthetics are covered for members who have had a mastectomy or other conditions that result in absence or defect of the breast.
Medical records must include:
Use the following HCPCS code descriptions when evaluating the member.
Mastectomy bras without integrated prosthesis form (L8000) and with integrated prosthesis form (L8001 and L8002) come in various materials and sizes to fit patients who have undergone a mastectomy. Authorization is not required for mastectomy bras. MHCP covers only one breast prosthetic per side for members who have undergone bilateral mastectomies.
A mastectomy sleeve (L8010) is covered for members with post-mastectomy lymphedema.
An external breast prosthesis garment (L8015) is covered for the postoperative period before a permanent breast prosthetic, or as an alternative to a mastectomy bra and breast prosthetic.
A mastectomy bra (L8000) is covered for members with mastectomy form (L8020) or silicone breast prosthetic without integrated adhesive (L8030) when the pocket of the bra is used to hold the prosthetic.
MHCP covers silicone breast prosthetics with integrated adhesives (L8031), prefabricated and custom nipple prosthetics (L8032 and L8033), and custom breast prosthetics (L8035). Authorization is required for custom breast and nipple prosthetics. Documentation must clearly articulate why prefabricated prosthetics do not satisfy the needs of the member. HCPCS code L8039 should only be used when a breast prosthetic is not described by a more specific HCPCS code (L8000 to L8035).
Eye and Iris Prostheses
Codes: 66683, C1839, V2623-V2629
Eye and iris prosthetics are covered for members who have absence, defect, shrinkage, or specific conditions of the eyes or iris.
Medical records must include:
Authorization is not required for eye prosthetics. Authorization is only required for subsequent new eye prosthetics if the current prosthetic device is less than five years old. Authorization is required for iris prosthetics.
Use the following categories and HCPCS code descriptions when evaluating the member.
Eye Prostheses
Eye prostheses are covered for members with absence or shrinkage of an eye due to disease, congenital defect of eye, surgery, or trauma.
Use the following HCPCS code descriptions when evaluating the member.
An ocular prosthetic (V2623) is an artificial eye that fits over an orbital implant and under the eyelids that produces the appearance of a normal human eye. Eye prosthetics assist in maintaining the internal orbital eye structures by filling in the void created by the missing natural eye.
Polishing and resurfacing (V2624) is covered for members without authorization two times per calendar year.
One enlargement (V2625) or reduction (V2626) is covered without authorization. Additional enlargements or reductions are rarely medically necessary and are therefore covered only when there is documentation in the medical record which supports medical necessity. This information must be made available to DHS or its authorized agent upon request.
MHCP covers scleral cover shells (V2627) and the fabrication and fitting of ocular conformers (V2628). HCPCS code V2629 should only be used when a facial prosthetic is not described by a more specific HCPCS code (V2623 to V2628).
Iris Prostheses
Iris prosthetics compensate for a defect of the iris of an eye. An iris prosthetic (C1839) is considered medically necessary for treatment of aniridia for members three years of age and older. Authorization is always required for iris prosthetics and device implantation. The implantation is described by CPT code 66683. Iris prosthetics are 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.
Facial Prostheses
Codes: L8040-L8049
Facial prosthetics are covered for members with loss or absence of facial tissue due to disease, congenital defect, surgery, or trauma.
Medical records must include:
Authorization is not required for facial prosthetics. Authorization is only required for subsequent new facial prosthetics if the current prosthetic device is less than five years old.
Use the following HCPCS code descriptions when evaluating the member.
A nasal prosthesis (L8040) is a removable superficial prosthesis, which restores all or part of the nose. It may include the nasal septum.
A midfacial prosthesis (L8041) is a removable superficial prosthesis, which restores part or all of the nose plus significant adjacent facial tissue but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue includes one or more of soft tissue of the cheek, upper lip, or forehead.
An orbital prosthesis (L8042) is a removable superficial prosthesis, which restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. This code does not include the ocular prosthesis component.
An upper facial prosthesis (L8043) is a removable superficial prosthesis, which restores the orbit plus significant adjacent facial tissue but does not include the nose or any intraoral maxillary component. Adjacent facial tissue includes one or more of soft tissue of the cheek or forehead. This code does not include the ocular prosthesis component.
A hemi-facial prosthesis (L8044) is a removable superficial prosthesis, which restores part or all of the nose plus the orbit plus significant adjacent facial tissue but does not include any intraoral maxillary component. This code does not include the ocular prosthesis component.
An auricular prosthesis (L8045) is a removable superficial prosthesis, which restores all or part of the ear.
A partial facial prosthesis (L8046) is a removable superficial prosthesis which restores a portion of the face, but which does not specifically involve the nose, orbit, or ear.
A nasal septal prosthesis (L8047) is a removable prosthesis, which closes a hole in the nasal septum but does not include superficial nasal tissue.
HCPCS code L8048 should only be used when a facial prosthetic is not described by a more specific HCPCS code (L8040 to L8047) or for components used to attach the facial prosthetic to a bone-anchored implant or to an internal prosthesis. HCPCS code L8048 code should not be used for implanted prosthesis-anchoring components. Medically necessary modifications and repairs are covered under L8048 for materials used and L8049 for labor components. MHCP allows up to six units of L8049 per day.
Scalp Hair Prostheses
Code: A9282
Scalp hair prostheses are considered medically necessary for treatment of medical conditions that result in hair loss. One medical wig is covered per calendar year with an annual limit of $1,000.
Batteries and Chargers
Codes: L7360-L7368
MHCP covers powered prosthetics, batteries, and chargers. Powered-prosthetic base codes are items that contain the power source. When a base code is dispensed, MHCP considers all batteries (L7360, L7364, L7367) and chargers (L7362, L7366, L7368) as included in the payment for the base item. There is no separate payment for these items billed concurrently with powered prosthetics.
Payment for batteries and chargers is included in the payment for these base codes:
Base Codes | Battery and Charger Codes |
L2005, L2006, L3904, L5781, L5782, L5856, L5857, L5858, L5859, L5973, L6026, L6700, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L8701, L8702 | L7360, L7362, L7364, L7366, L7367, L7368 |
Many powered prosthetic base codes are used concurrently with add-ons that derive power from the power source. When an add-on to a base code is dispensed, MHCP considers all batteries (L7360, L7364, L7367) and chargers (L7362, L7366, L7368) as included in the payment for the item. There is no separate payment for these items billed concurrently with powered prosthetic add-ons.
Payment for batteries and chargers is included in the payment for these add-on codes and the appropriate base code:
Add-On Codes | Base Codes | Battery and Charger Codes |
L5827, L5969, L6621, L6638, L6646, L6648, L6715, L6880, L6881, L6882, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259 | L5781, L5782, L5856, L5857, L5858, L5859, L5973, L6026, L6700, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975 | L7360, L7362, L7364, L7366, L7367, L7368 |
MHCP pays for one battery and charger annually only when the original item no longer functions.
Devices for Bathing or Recreation
Devices for purposes of bathing or showering and for purposes of recreation are covered. 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 orthotics or initial prosthetics for bathing or showering. Use modifier U1 for billing. Bathing devices only require authorization if they are the member’s third device. Authorization is required for subsequent new prosthetic devices for replacing the member’s initial device for any purpose. It is the expectation of MHCP that devices for bathing or showering are nonelectronic and made from the least costly items and waterproof materials.
Recreational devices are covered with authorization if all of the following criteria are met:
Repairs and Replacements
Codes: L4000-L4210, L7510, L7520
Repairs to devices are covered without authorization with the following exceptions:
Replacements for a device or parts of a device are covered, without regard to useful lifetime restrictions, if ordered by an eligible provider because:
Authorization from a provider is required if the device or part being replaced is less than three years old.
Reasonable Useful Lifetime
The usual reasonable useful lifetime (RUL) of five years for durable medical equipment DME does not apply to prosthetics or custom orthotics. Custom orthotics include devices that are custom fabricated, or custom fitted to a specific member based on their unique physical condition. MHCP covers medically necessary repairs and replacements for parts and devices. Members cannot automatically obtain a new device if the original is still in working order.
MHCP pays for the initial prosthetic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational prosthetics and subsequent new or replacement prosthetics for any purpose. MHCP pays for custom orthotic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational orthotics and subsequent new or replacement orthotic devices if the current orthotic device is less than three years old.
Noncovered Services
MHCP does not cover the following:
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:
Authorization is not required for immediate postsurgical or early fittings (L5400 to L5460, L6037, L6380 to L6388), initial prostheses (L5500, L5505), preparatory prostheses (L5510 to L5600, L6580 to L6590), or the first two test sockets (L5618 to L5628, L6029, L6680 to L6684). The device must be guaranteed to fit the member for a minimum of period of 90 days. Any modifications to a device or its parts are noncovered for 90 days after the date of delivery.
Refer to the Medical Supply Coverage Guide for information on MHCP authorization requirements and quantity limits by HCPCS code.
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.
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.
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.
Body-powered prosthetic: Upper body prosthetic that uses body movements to control the device. These protheses typically feature a cable and hardness, can withstand rugged environments, are lightweight, and used for performing heavy-duty activities and manual labor. Body-powered prostheses typically feature a cable and harness.
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.
K-level: Medicare-assigned rating system to indicate an amputee’s rehabilitation potential.
Myoelectric or hybrid prosthetic: Upper body prosthetic that uses electromyographic signals in muscle contractions to control the device. The member’s physical movements in the residual limb generate electrical signals, which electrodes then send to a controller, thereby triggering the device to correspond with the member’s intended movement. Hybrid systems use a combination of body and external power control components.
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.
Passive prosthetic: Upper body prosthetic that does not move on its own. These prostheses are lightweight, may resemble the missing limb, and enhance the member’s condition by stabilizing or carrying objects.
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 or off-the-shelf (OTS): 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.
Legal References
Minnesota Statutes, 62Q.661 (Coverage for Orthotic and Prosthetic Devices)
Minnesota Statutes, 256B.0659, subdivision 2 (Orthotic and Prosthetic Devices, Supplies, and Services)
Code of Federal Regulations, title 42, Section 414.202 (3) (Prosthetic Definition)
Code of Federal Regulations, title 42, Section 414.210 (f) (Reasonable Useful Lifetime)
Centers for Medicare & Medicaid Services (CMS) Policy Article A52496 (Lower Limb Prostheses)
CMS Policy Article A55426 (Standard Documentation Requirements)
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