CurrentAnthemPolicy G-06084

Prosthetic and Orthotic Devices

Reimbursement rules for prosthetic and orthotic devices provided or ordered by a physician or qualified provider, including repair and replacement conditions, for Anthem members governed by state and contract requirements.

Policy Summary

PayerAnthem

PolicyProsthetic and Orthotic Devices

Policy CodePolicy G-06084

Change TypeMaterial revision — added member-owned device repair language

Effective DateOct 14, 2024

Next Review Date

Key ActionObtain prior authorization and document medical necessity in the record; reimbursements follow applicable fee schedule or contracted rate.

SourceLink

POLICY UPDATE CHANGES

added language for member owned devices.

≥5 yearsminimum reasonable useful lifetime for device consideration

up to replacement costrepair reimbursement cap

no reimbursement during warrantywarranty exclusion

police reportdocumentation required for replacement after theft

Coverage and Reimbursement Criteria

Coverage Criteria

Anthem allows reimbursement when items are ordered/provided by a physician or qualified provider and used in accepted medical practice, subject to contract and state requirements.

Item is provided as part of a physician's services or ordered by a physician or other qualified healthcare provider and used in accepted medical practice.

Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the prosthetic or orthotic device dispensed.

Labor, design, and repair related to the device are separately reimbursable expenses.

ALL of the following

Repair is necessary to make the device serviceable.

Policy Summary

PayerAnthem

PolicyProsthetic and Orthotic Devices

Policy CodePolicy G-06084

Change TypeMaterial revision — added member-owned device repair language

Effective DateOct 14, 2024

Next Review Date

Key ActionObtain prior authorization and document medical necessity in the record; reimbursements follow applicable fee schedule or contracted rate.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization, Medical Necessity, and Provider Responsibilities

Prior Authorization

Authorization and medical necessity required; follow coding and reimbursement rules

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; reimbursement is based on the applicable fee schedule or contracted/negotiated rate. Ensure proper coding and documentation support in the medical record; failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, or recovery/recoupment of payment.

Obtain prior authorization or confirm medical necessity per member’s state/contract when required for the procedure and diagnosis.
Bill using appropriate CPT, HCPCS, and/or revenue codes fully supported by the medical record or office notes.
Follow applicable fee schedule or contracted rate for reimbursement.

Key Definitions

Prosthetic device

DefinitionAn artificial structural and functional replacement of a limb/appendage or internal organ, or all or part of the function of a permanently inoperative or malfunctioning internal body organ.

ScopeIncludes prostheses that replace anatomical structures and/or restore function of permanently inoperative internal organs.

Reference contextDefined in the policy's References and Research Materials section alongside related reimbursement guidance.

Orthotic device

DefinitionA brace with rigid metal or plastic stays applied to the body for support or immobilization, to correct or prevent deformity, or to assist or restore function.

Primary purposesSupport/immobilization, deformity correction/prevention, and assistance or restoration of function.

Material examplesTypically constructed with rigid metal or plastic stays as described in the policy references.

OpenPayer

Prosthetic and Orthotic Devices

Coverage and Reimbursement Criteria

Billing Codes and Reimbursement Limits

Authorization, Medical Necessity, and Provider Responsibilities

Key Definitions