CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Orthotic and Prosthetic Services Mandate

Administrative policy documenting Rhode Island state-mandated coverage requirements for orthotic and prosthetic services that applies to BlueCHiP for Medicare and Commercial Products and other applicable RI health plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOrthotic and Prosthetic Services Mandate

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateFeb 11, 2006

Next Review DateN/A

Key ActionDo not submit prior authorization for orthotic or prosthetic services for BlueCHiP for Medicare and Commercial Products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2006-02-11effective date

2019-07-17last updated

No prior authBlueCHiP for Medicare and Commercial

Corrective shoes excludedexception

§27-20-52governing law

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Covered when statutory and plan conditions met

Coverage and applicability per BlueCHiP and RI statute

State-mandated coverage: Insurers delivering or renewing policies in RI that provide medical coverage must provide coverage for orthotic and prosthetic devices equivalent to federal Medicare benefits (42 U.S.C. and 42 CFR references).

Referenced statute §27-20-52; see RI statute requirements for federal benefit parity.

Product-specific rules: For BlueCHiP for Medicare and Commercial Products: orthotic and prosthetic services are a covered benefit and prior authorization review is not required; corrective or orthopedic shoes and orthotic devices used with footwear are excluded unless for treatment of diabetes.

Benefits may vary by group/contract; refer to benefit booklet.

Repair and replacement of orthotic or prosthetic devices are covered subject to co-payments and deductibles unless necessitated by misuse or loss.

Insurer may require provision by RI-licensed vendors/providers if coverage is through a managed care 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 exception and exclusion are stated explicitly for BlueCHiP products and reflect the Rhode Island statutory scope for orthotic and prosthetic benefits. Benefits for orthotic and prosthetic services otherwise apply when statutory and plan conditions are met; refer to the member's contract or benefit booklet for any product- or group-specific variations.

For BlueCHiP for Medicare and Commercial Products, orthotic and prosthetic services are a covered benefit and prior authorization review is not required. However, plan contracts may vary and a health insurance contract could require prior authorization for orthotic or prosthetic devices under the same rules that apply to other covered benefits.

This policy does not establish clinical medical necessity criteria. The section labeled "Medical Criteria" is not applicable because this document serves as an administrative statement of Rhode Island statutory coverage requirements rather than a clinical-necessity standard.

Providers should follow applicable statutory requirements and the member's benefit contract for coverage determinations; clinical documentation requirements or prior authorization practices (if any) are governed by the member's specific plan terms rather than by clinical criteria in this policy.

Provider Actions and Billing

Prior Authorization

Prior Authorization Requirements

BlueCHiP for Medicare and Commercial Products: prior authorization review is not required. Contract-level variations may apply; a health plan may require prior authorization in the same manner as for other covered benefits.

Prior authorization not required for BlueCHiP for Medicare and Commercial Products
Plan or contract may still require prior authorization per (c)

Note

Provider Action — Vendor/Provider Requirements

Provider note: orthotic and prosthetic services are a covered benefit. Ensure devices and services are provided by appropriately licensed vendors/providers when coverage is through a managed care plan.

Orthotic and prosthetic services covered for BlueCHiP for Medicare and Commercial Products
If managed care plan, devices/services may be required to be from Rhode Island–licensed vendor/provider per (f)

Documentation Required

Documentation and Medical Necessity

Documentation and medical necessity: coverage is limited to the most appropriate model that adequately meets the medical needs of the patient as determined by the treating physician. Repair and replacement are covered unless due to misuse or loss. Maintain clear clinical documentation supporting choice of device, medical necessity, and justification for repair or replacement.

Covered only for the most appropriate model that meets the patient's medical needs (d)
Repair and replacement covered subject to cost‑sharing unless due to misuse or loss (e)
Document treating physician's determination of medical necessity and rationale for model selection

Denial Risk

Coverage Exceptions and Denial Risks

Coverage exceptions and potential denials: corrective or orthopedic shoes and orthotic devices used in connection with footwear are excluded except when used for the treatment of diabetes. Claims may be denied if documentation does not support medical necessity, if devices are not the most appropriate model, or if repair/replacement is due to misuse or loss.

Corrective/orthopedic shoes and footwear-related orthotics NOT covered unless for treatment of diabetes
Denial risks: insufficient documentation of medical necessity, inappropriate device model, repair/replacement due to misuse or loss

Background

Rhode Island statute §27-20-52 provides definitions and the statutory framework for orthotic and prosthetic services. An "orthosis" is defined as a custom-fabricated brace or support designed based on medical necessity and explicitly excludes prefabricated or direct-formed devices and a list of common assistive items (for example, canes, crutches, elastic hose, fabric supports and similar over-the-counter devices).

The practice of orthotics includes evaluation, measuring, design, fabrication, assembly, fitting, adjustment, servicing and the initial training necessary to accomplish fitting of an orthosis. Prosthetics is the science and practice of evaluation, measurement, design, fabrication, fitting, alignment, adjustment, training and ongoing care for non-implanted artificial limbs and external body parts.

The statute also ties reimbursement to federal reimbursement rates by referencing the current Medicare fee schedule (HCPCS) and supports coverage and payment for orthotic and prosthetic services consistent with those federal references.

Definitions

Orthosis / Orthotics — definition and scope

DefinitionOrthosis: a custom fabricated brace or support designed based on medical necessity. Excludes prefabricated or direct-formed orthotic devices and many common assistive items (e.g., canes, crutches, elastic hose, fabric supports, low-temperature formed splints).

Scope of servicesOrthotics: the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, adjusting, servicing, and providing initial training necessary for proper fitting of an orthosis to support, correct, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.

Clinical activities includedEvaluation, treatment and consultation; basic observational gait and postural analysis; periodic evaluation and continuing patient care to assess tissue effects and assure fit and function.

Exclusions / not orthosesDoes not include prefabricated/direct-formed devices and specified assistive devices commonly stocked by pharmacies or stores (e.g., commercially available knee orthoses post-injury/surgery, spastic muscle-tone inhibiting orthoses, upper extremity adaptive equipment, finger/hand splints, corsets, trusses, elastic hose, canes, crutches, cervical collars, dental appliances, wigs).

Prosthesis / Prosthetics — definition and scope

DefinitionProsthesis: an artificial limb or external medical device that is not surgically implanted and is used to replace a missing limb, appendage, or other external human body part; in lower-extremity applications may be alignable or capable of weight bearing.

Scope of servicesProsthetics: the science and practice of evaluation, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, servicing, and providing initial training necessary to accomplish fitting of a prosthesis for replacement of external body parts lost due to amputation or congenital deformity/absence.

Clinical activities includedGeneration of image/form/mold to replicate body segment and create a socket, gait analysis and clinical assessment to refine and align prosthetic components, and continuing patient care with periodic evaluation to assure fit, function, stability, and safety.

ExclusionsDoes not include artificial eyes, ears, noses, dental appliances, ostomy products, eyelashes, or wigs.

OpenPayer

Orthotic and Prosthetic Services Mandate

Coverage Criteria

Coding

Provider Actions and Billing

Background

Definitions