CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Orthotic and Prosthetic Services Coverage

Defines state-mandated coverage guidelines for orthotic and prosthetic services for BlueCHiP for Medicare and Commercial products in Rhode Island and describes exceptions and benefit limits for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOrthotic and Prosthetic Services Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 11, 2006

Next Review DateN/A

Key ActionPrior authorization is not required for BlueCHiP for Medicare and Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No prior authBlueCHiP for Medicare and Commercial

Since 2006State mandate effective date

Non-diabetic shoes excludedCoverage exception

Cost-sharing appliesRepairs/replacements

Coverage criteria and limitations

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Primary coverage: Orthotic and prosthetic services are a covered benefit for BlueCHiP for Medicare and Commercial products; covered benefits are limited to the most appropriate model that adequately meets the medical needs of the patient as determined by the insured's treating physician.

Benefits may vary by group/contract; refer to member documents.

Repairs and replacements: Repair and replacement of orthotic or prosthetic devices are covered subject to copayments and deductibles unless necessitated by misuse or loss.

Insurer may exclude repair/replacement for misuse or loss per member contract.

Prior authorization: A health insurance contract, plan, or policy may require prior authorization for orthotic and prosthetic devices in the same manner as for any other covered benefit.

Prior authorization is not required by BlueCHiP for Medicare and Commercial products, but individual plans may impose requirements.

Vendor and provider requirements: If coverage is provided through a managed care plan, the insurer may require that devices be provided by a vendor and services rendered by a provider licensed by the state of Rhode Island to provide orthotics and prosthetics.

Verify vendor/provider licensure and contract requirements with the plan.

Corrective or orthopedic shoes and orthotic devices used in connection with footwear are not covered except when provided for the treatment of diabetes. This exclusion applies to corrective/orthopedic shoes and orthotic devices that are intended to be used with footwear and reflects the policy exception for diabetic treatment.

Orthotic and prosthetic services otherwise remain a covered benefit for BlueCHiP for Medicare and Commercial products when the general coverage criteria are met and the device selected is the most appropriate model to meet the member’s medical needs as determined by the treating physician. Benefits may vary by group/contract; refer to member documents for specific plan provisions.

Benefits and eligibility are determined by the member’s subscriber agreement, member certificate, and/or employer agreement; those documents supersede this medical policy. If a service is determined to be not medically necessary or is a non‑covered benefit under the member’s plan, the provider may not bill the member unless the member has been informed and has agreed in writing in advance to proceed at their own expense.

Providers should follow applicable participation agreements and plan-specific provisions when advising members about coverage and cost responsibility for services that are excluded or deemed not medically necessary.

Provider requirements and actions

Prior Authorization

Prior authorization

Prior authorization is not required for BlueCHiP for Medicare and Commercial products. Plan-specific exceptions may apply; verify member's subscriber agreement or employer group contract for any differing requirements.

BlueCHiP for Medicare and Commercial Products: prior authorization review is not required

Documentation Required

Member eligibility and documentation

Confirm benefits and eligibility against the member's subscriber agreement, member certificate, and/or employer agreement before providing services. If a service is determined to be not medically necessary or is a non-covered benefit, providers must inform the member and obtain written agreement if the member elects to proceed at their own expense. Follow participation agreement provisions for billing members.

Benefits/eligibility determined by subscriber agreement or employer contract
Obtain written member agreement before charging member for non-covered services

Denial Risk

Coverage exceptions and denial triggers

Corrective or orthopedic shoes and orthotic devices used in connection with footwear are not covered except when used for the treatment of diabetes. Repair and replacement are covered unless due to misuse or loss. Coverage may be limited to the most appropriate model that adequately meets the patient's medical needs as determined by the treating physician.

Corrective/orthopedic shoes and orthotic devices: NOT covered unless for diabetes
Repair and replacement covered unless due to misuse or loss
Coverage limited to most appropriate model as determined by treating physician

Billing Rule

Provider actions

Follow applicable billing and documentation practices. If coverage is provided through a managed care plan, the insurer may require that orthotic and prosthetic devices and services be provided by vendors and providers licensed by the State of Rhode Island.

Ensure vendor/provider licensure in RI when required by managed care plan
Adhere to standard billing, coding, and documentation practices

Clinical background

An orthosis is a fabricated brace or support designed and provided based on medical necessity to support, align, prevent, or correct neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity. Orthotic practice includes evaluation, design, fitting, adjustment, and periodic follow-up to assure proper fit and function.

The policy excludes many low‑support or prefabricated devices from the orthosis definition and explicitly excludes commonly available assistive items (for example, commercially available knee orthoses used following injury or surgery, fabric or elastic supports, corsets, low‑temperature formed plastic splints, canes, crutches, cervical collars, and other similar devices). Additionally, corrective or orthopedic shoes and orthotic devices used with footwear are not covered unless provided for the treatment of diabetes.

Key definitions

Orthosis — fabricated brace or support definition and exclusions

DefinitionA fabricated brace or support designed based on medical necessity to provide support, alignment, correction, or alleviation of neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.

IncludesEvaluation, design, fabrication, fitting, adjustment/servicing, and periodic follow-up to ensure proper fit and function and to assess effects on patient tissues.

Excludes - prefabricated/direct-formed devicesPrefabricated or direct-formed orthotic devices are not included in this definition.

Excludes - common assistive itemsCommercially available knee orthoses used following injury/surgery, spastic muscle-tone inhibiting orthoses, upper extremity adaptive equipment, finger/hand splints, wrist gauntlets, face masks after burns, fabric or elastic supports, corsets, low-temperature formed plastic splints, trusses, elastic hose, canes, crutches, cervical collars, dental appliances, and similar items commonly stocked in pharmacies or stores are excluded.

PurposeTo provide support, alignment, prevent or correct deformity, and improve safety, efficiency of mobility or locomotion.

Prosthesis — external artificial limb definition

DefinitionAn external, non-surgically implanted artificial limb or appendage intended to replace a missing body part (e.g., artificial limb, hand, or foot).

IncludesDesign, fabrication, socket creation, alignment, adjustment/servicing, initial fitting, and ongoing patient care including periodic evaluation and training (e.g., gait training) to maximize function, stability, and safety.

PurposeTo support body weight and to improve or restore function or cosmesis, or both, for limbs lost due to amputation or congenital absence.

ExcludesArtificial eyes, ears, noses, dental appliances, eyelashes, wigs, and similar products are not considered prostheses under this definition.

Practice scopeClinical assessment, observational analysis, generation of body/segment models or molds, and mechanical refinement to maximize prosthetic function and fit.