CurrentBlue Cross Blue Shield - NevadaPolicy G-06084

Prosthetic and Orthotic Devices, Reimbursement Policy

Defines Anthem Blue Cross and Blue Shield - Nevada reimbursement rules for prosthetic and orthotic devices, including coverage, repairs, replacements, and exclusions, applying to services ordered by physicians or qualified providers and billed to the health plan.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProsthetic and Orthotic Devices, Reimbursement Policy

Policy CodePolicy G-06084

Change TypeClarified — repair reimbursement to member-owned devices

Effective DateOct 14, 2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines; reimbursement is based on the applicable fee schedule or contracted rate.

SourceLink

POLICY UPDATE CHANGES

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

≥5 yrsuseful lifetime

G-06084policy id

10/14/2024effective

Police reporttheft replacement

Reimbursement Coverage Rules

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Reimbursement criteria

Covered when ALL of the following are met:

Devices provided as part of a physician's services or ordered by a physician or other qualified healthcare provider and used in accepted medical practice (unless superseded by provider, state, federal, or CMS contracts/requirements).

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

Design, materials, measurements, fabrication, testing, fitting, and training in the use of the device are included in device reimbursement and are not separately reimbursable.

Repair coverage — reimbursement allowed when ANY of the following apply:

Device is no longer covered under the supplier's or manufacturer's warranty.
Repair is necessary to make the device serviceable.
Reimbursement for repair is limited to up to the estimated expense of replacement of the device.
Operational note: the health plan allows reimbursement of repairs to member-owned devices.

Replacement coverage — reimbursement allowed when ANY of the following apply:

Substantial change in the patient's growth and/or weight.
Change in the patient's condition.
Permanent and/or accidental damage to the device.
Irreparable wear, taking into consideration a reasonable useful lifetime of the device of not less than five years from delivery to the member.

Nonreimbursable (any of the following make the item nonreimbursable):

Provision of a device that exceeds the benefit limit unless authorized through medical necessity.
Aesthetic-only devices provided for member or caregiver preference.
Enhancements or upgrades for convenience of the member or caregiver.
Devices considered experimental or investigational.
Repair or replacement due to abuse or neglect.
Over-the-counter orthotic devices.

Payment is made according to the applicable fee schedule or contracted/negotiated rate for the dispensed device.

Billing Codes and Useful Lifetime

Billing codesmixed

CPT, HCPCS, revenue codes

Claims should use appropriate CPT, HCPCS, and revenue codes; coding must be supported in the medical record.

Useful lifetime threshold

Useful lifetime thresholdNot less than five years from delivery (reasonable useful lifetime based on delivery date).

Replacement considerationIrreparable wear considered in relation to the ≥5-year useful lifetime when determining replacement eligibility.

Repair vs replacementRepairs may be reimbursed up to the estimated expense of replacement; replacement considered for permanent/accidental damage or substantial change in patient condition.

Authorization, Medical Necessity, and Billing Guidance

Prior Authorization

Authorization, medical necessity, and reimbursement basis

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 for the prosthetic or orthotic device dispensed. Design, materials, measurements, fabrication, testing, fitting, and training are included in device reimbursement and are not separately reimbursable. Repairs are reimbursable when the device is no longer covered by the supplier's or manufacturer's warranty or when necessary to make the device serviceable (reimbursement up to the estimated expense of replacement); the health plan also allows reimbursement of repairs to member-owned devices. Replacements are reimbursable for substantial change in growth/weight, change in condition, permanent/accidental damage, or irreparable wear considering a reasonable useful lifetime of not less than five years from delivery.

Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
Bill using appropriate CPT, HCPCS, and revenue codes fully supported in the medical record; failure to follow coding/billing guidelines may lead to recoupment, denial, or adjustment of payment.
Do not bill separately for design, materials, measurements, fabrication, testing, fitting, or training — these are included in device reimbursement.
Repairs: eligible when out of supplier/manufacturer warranty or needed to make the device serviceable; reimbursed up to estimated replacement cost — applies to member-owned devices.
Replacements: eligible for substantial growth/weight change, condition change, permanent/accidental damage, or irreparable wear — useful lifetime not less than five years from delivery.

Key Definitions

Prosthetic device

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

ScopeApplies to prosthetic devices considered for reimbursement under the policy when ordered by a physician or qualified provider.

Related policy noteReimbursement includes design, materials, fabrication, testing, fitting, and training; these are not separately reimbursable.

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.

Common usesSupport or immobilization of a body part, correction or prevention of deformity, and assistance or restoration of function.

Reimbursement contextOrthotic devices are reimbursable when provided as part of physician services or ordered by a qualified provider and used in accepted medical practice.