CurrentAnthemPolicy G-06084

Prosthetic and Orthotic Devices, Reimbursement Policy

Governance of reimbursement for prosthetic and orthotic devices provided or ordered by physicians or qualified providers for AMH Health Medicare Advantage members; describes when devices, repairs, and replacements are reimbursable and nonreimbursable.

Policy Summary

PayerAnthem

PolicyProsthetic and Orthotic Devices, Reimbursement Policy

Policy CodePolicy G-06084

Change TypeAdded reimbursement for repairs to member-owned devices

Effective DateOct 14, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and bill using appropriate CPT/HCPCS/revenue codes supported by the medical record.

SourceLink

POLICY UPDATE CHANGES

Added language allowing reimbursement of repairs to member owned devices.

Policy template updated during prior review.

Policy language updated on 05/27/2020.

>=5useful lifetime (yrs)

G-06084document id

10/14/2024effective

Coverage Criteria for Prosthetic and Orthotic Devices

Coverage criteria

Covered or not covered under the following conditions:

Allowed when 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

Includes design, materials, measurements, fabrications, testing, fitting, and training in the use of the device as part of the device reimbursement

Repairs reimbursed when

Necessary to make the device serviceable
Device is no longer covered under the supplier's or manufacturer's warranty
Repair cost is up to the estimated expense of replacement of the device

Policy Summary

PayerAnthem

PolicyProsthetic and Orthotic Devices, Reimbursement Policy

Policy CodePolicy G-06084

Change TypeAdded reimbursement for repairs to member-owned devices

Effective DateOct 14, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and bill using appropriate CPT/HCPCS/revenue codes supported by the medical record.

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.

Repairs to member-owned devices are eligible for reimbursement

Replacements allowed for

Change in the patient's condition
Substantial change in patient's growth and/or weight
Permanent and/or accidental damage
Irreparable wear, taking into consideration a reasonable useful lifetime of not less than 5 years from delivery to the member
Loss of the item from theft, fire, or natural disaster (police report required for theft)

Not reimbursed when

Provision of a device that exceeds the benefit limit unless authorized through medical necessity
Enhancements or upgrades for the convenience of the member or caregiver
Aesthetic appearance of a device for member or caregiver preference
Device considered experimental or investigational
Repair or replacement due to abuse or neglect
Repair or replacement during the warranty period
Over-the-counter orthotic devices
Dental prosthetics (considered via delegated agreements with contracted dental vendors)

Billing Codes and Useful Lifetime

Billing codes requiredmixed

CPT/HCPCS/Revenue

Policy requires use of CPT, HCPCS, and/or revenue codes on claim submissions as appropriate.

Minimum reasonable useful lifetime

Minimum useful lifetimeNot less than 5 years from delivery to the member

Replacement considerationIrreparable wear is considered with the >=5-year useful lifetime when assessing replacement

Context for repairsReplacements allowed for permanent/accidental damage, change in condition, substantial growth/weight change, or loss from theft/fire/natural disaster

Authorization, Reimbursement Basis, and Provider Responsibilities

Prior Authorization

Authorization and reimbursement basis

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; reimbursement is determined by the applicable fee schedule or contracted/negotiated rate. The design, materials, measurements, fabrication, testing, fitting, and training for the device are included in the device reimbursement and are not separately reimbursable.

Obtain any required authorizations and document medical necessity consistent with the procedure, diagnosis, and member’s state of residence.
Bill using applicable fee schedule or contracted/negotiated rates; do not bill separately for design, materials, measurements, fabrication, testing, fitting, or training—these are included in device 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 replacement of structural and functional aspects of limbs, appendages, or internal organs

Policy useUsed to determine reimbursement eligibility for prosthetic devices and related repairs/replacements

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, correction/prevention of deformity, assistance or restoration of function

Material examplesTypically uses rigid metal or plastic stays