CurrentBlue Cross Blue Shield - MainePolicy G-06084

Prosthetic and Orthotic Devices, Reimbursement Policy

Reimbursement rules for prosthetic and orthotic devices provided or ordered by physicians or other qualified providers, describing when devices, repairs, and replacements are reimbursable and when they are excluded; applies to members under the payer's applicable benefit plans.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProsthetic and Orthotic Devices, Reimbursement Policy

Policy CodePolicy G-06084

Change TypeAdded operational clarification

Effective DateOct 14, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and bill with appropriate codes for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that the health plan allows reimbursement of repairs to member owned devices.

>=5minimum useful lifetime (years)

allowedrepairs reimbursed

police reporttheft replacement doc

listedexplicit exclusions

Reimbursement and Exclusion Criteria

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProsthetic and Orthotic Devices, Reimbursement Policy

Policy CodePolicy G-06084

Change TypeAdded operational clarification

Effective DateOct 14, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and bill with appropriate codes for reimbursement.

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.

Reimbursement Criteria

Conditions under which prosthetic and orthotic devices, repairs, and replacements are reimbursable and conditions that exclude reimbursement.

Reimbursement allowed when device is provided as part of a physician's services or ordered by a physician or other qualified healthcare provider and is used in accepted medical practice; reimbursement is based on the applicable fee schedule or contracted/negotiated rate; included components (design, materials, measurements, fabrication, testing, fitting, and training) are not separately reimbursable.

Repair reimbursement

Repair is necessary to make the device serviceable.
Device is no longer covered under the supplier's or manufacturer's warranty.
Cost of repair does not exceed the estimated expense of replacement.
Repairs to member-owned devices are allowed.

Replacement reimbursement

Replacement is due to change in the patient's condition.
Replacement is due to substantial change in the patient's growth and/or weight.
Replacement is due to permanent and/or accidental damage.
Replacement is due to irreparable wear, taking into consideration a reasonable useful lifetime of not less than five years from delivery to the member.
Replacement is due to loss from theft, fire, or natural disaster (police report required for theft).

Exclusions (non-reimbursable)

Provision of a device that exceeds the benefit limit unless authorized through medical necessity.
Enhancements or upgrades for convenience of the member or caregiver.
Aesthetic appearance of a device for member or caregiver preference.
Devices considered experimental or investigational.
Repair or replacement due to abuse or neglect.
Repair or replacement during the warranty period.

Documentation and billing notes

Design, materials, measurements, fabrication, testing, fitting, and training are included in device reimbursement and are not separately reimbursable expenses.
In instances of theft, a police report is required for consideration of replacements.

Billing Codes and Useful Lifetime

Billing Codesmixed

CPT/HCPCS

Use appropriate CPT, HCPCS, and revenue codes; standard correct coding applies.

Useful lifetime for device replacement

Minimum useful lifetime (years)Not less than 5 years from delivery to the member

Replacement considerationIrreparable wear considered relative to the 5-year useful lifetime before replacement is allowed

Exception for other causesReplacement allowed for change in patient condition, substantial growth/weight change, permanent/accidental damage, or loss from theft/fire/natural disaster

Authorization, Billing and Documentation Requirements

Note

Authorization, Billing, and Documentation Requirements for Prosthetic/Orthotic Services

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; reimbursement is based on the applicable fee schedule or contracted/negotiated rate and requires proper coding and documentation. Design, materials, measurements, fabrication, testing, fitting, and training are included in device reimbursement and are not separately reimbursable. For repairs and replacements, document that the device is no longer under supplier/manufacturer warranty when repairing, and for replacement due to theft provide a police report.

Obtain prior authorization and ensure medical necessity criteria are met for the procedure and diagnosis.
Bill using appropriate CPT, HCPCS, and/or revenue codes; charges must be fully supported in the medical record or office notes.
Do not bill separately for design, materials, measurements, fabrication, testing, fitting, or training — these are included in device reimbursement.
For repairs: confirm device is not under supplier/manufacturer warranty and document necessity to make the device serviceable; repair reimbursement cannot exceed estimated replacement cost.
For replacement due to theft: include a police report as documentation.

Key Definitions

Prosthetic device — definition

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.

Included servicesDesign, materials, measurements, fabrication, testing, fitting, and training are included in device reimbursement and not separately payable.

Reimbursement contextReimbursed when provided as part of a physician's services or ordered by a physician or qualified provider and used in accepted medical practice.

Orthotic device — definition

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.

Use casesCovered when ordered by a physician or qualified provider and used in accepted medical practice; reimbursement follows applicable fee schedule or contracted rate.

Repairs and replacementsRepairs allowed when necessary to make the device serviceable and not covered by warranty; replacements allowed for clinical changes, damage, or loss.