RetiredCapital BluecrossPolicy MP 6.018

Prosthetics and Accessories

Defines medical necessity, coverage limits, and examples for prosthetic devices and related accessories for members of Capital Blue Cross products; applies to providers and claims adjudicators. Medicare guidelines prevail unless superseded by specific policy statements.

Policy Summary

PayerCapital Bluecross

PolicyProsthetics and Accessories

Policy CodePolicy MP 6.018

Change TypeRetired (11/10/2023)content revisions and policy moves

Effective DateRETIRED 12/1/2024

Next Review DateN/A

Key ActionConsult the member's benefit plan or contact Capital Blue Cross to determine preauthorization requirements.

SourceLink

POLICY UPDATE CHANGES

Policy was retired on 11/10/2023.

Breast prosthetics were moved into a separate policy (MP 1.103).

11/10/2023 Retirement.

1/9/19 Criteria added stating that the MyoPro orthotic is considered investigational.

5/08/18 Criteria added for prosthetics bras as well as for wigs.

2/1/2022 Consolidated sections and added medically necessary reasons for wigs (alopecia areata/totalis/universalis); breast prosthetics moved into MP 1.103.

1Policy retired date present

Policy retiredRetirement recorded

60%Replacement threshold

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Named prosthetic categories

MP 1.103Related breast prosthetics policy

Coverage Criteria — Prosthetics & Accessories

General prosthetic medical necessity

Covered when ALL of the following are met

General medical necessity: Device is prescribed by a physician

Function replacement or organ replacement: Device replaces all or part of an absent internal body organ (including contiguous tissue) OR replaces all or part of the function of a permanently inoperative or malfunctioning body part resulting from disease, injury, or congenital deficit

Includes surgically implanted or externally worn prosthetics

Cost-effectiveness: Device is the most cost-effective medically necessary device required to restore lost body function

Policy status and historical criteria changes

Policy statements and criteria referenced in history; specific coverage criteria not present in these excerpts.

Policy status: Policy MP 6.018 was retired on 11/10/2023.

Retired — refer to current policies (e.g., MP 1.103 for breast prosthetics)

Prosthetic devices dispensed to a patient prior to performance of the procedure that will necessitate the use of the device are not covered. Replacement of lost or stolen devices is not covered within the expected useful life of the item.

No additional explicit exclusions are detailed in the provided excerpts of this policy beyond those already stated. The policy history notes administrative and coding reviews but does not add other exclusionary language in these chunks.

The MyoPro Orthotic System is designated Investigational in this policy because there is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with the product.

The policy history records that criteria stating the MyoPro orthotic is considered investigational were added on 1/9/19.

Coding, Repair & Replacement Thresholds

Specific coding not providedmixed

No codes listed

Coding reviewed / LCD updates notedmixed

No codes listed

Repair cost threshold for replacement — inv-09

Repair cost threshold for replacementRepairs costing more than 60% of the cost of a replacement device or part make replacement eligible.

Replacement eligibility triggersReplacement also eligible for change in physiological condition or irreparable change in the device or part.

ScopeApplies to prosthetic devices and parts that replace all or part of an absent body organ or a permanently inoperative or malfunctioning body part.

LCD updates — inv-10

LCD update reasonLCD numbers changed due to Novitas update to ICD-10.

Effect on specific codes

Provider Actions, Authorization & Documentation

Prior Authorization

Prior authorization is not specified in the policy excerpt. Preauthorization requirements vary by plan; providers should consult the member's health benefit plan or contact Capital Blue Cross to determine whether preauthorization is required for the specific product.

Check member's health benefit plan for preauthorization requirements.
Contact Capital Blue Cross for benefit information when unclear.

Step Therapy

The policy does not describe any step therapy requirements for prosthetic devices. There are no step therapy rules referenced in the provided policy excerpts.

Definitions and Key Terms

Basic Activities of Daily Living — inv-20

DefinitionBasic Activities of Daily Living include and are limited to walking in the home, eating, bathing, dressing, and homemaking.

PurposeUsed to assess functional need for prosthetic or supportive devices.

LimitationsList is limited to the activities named; other activities are not included in this definition.

Functional Mobility — inv-21

DefinitionFunctional Mobility refers to the ability to move from one place to another to complete an activity or task.

Clinical useAssessing a patient’s need for prosthetic devices that restore or enable movement between locations.

Background — Prosthetics Overview

Prosthetics are artificial appliances used to replace all or part of a body organ or to substitute the function of a permanently inoperative, absent, or malfunctioning body part. Devices must be prescribed by a physician and are intended to restore lost body function; fitting, adjustments, repairs, and replacements are eligible when the device replaces an absent or permanently inoperative body part. Surgical implantation or attachment of covered prosthetics is considered medically necessary regardless of measured functional improvement.

Revision History & Policy Status

2015-09-29consensus_review

CAC consensus review; no change to policy statements; references reviewed and FEP variation added.

2016-07-15administrative_update

Administrative update: LCD revised to reflect change from NHIC to Noridian LCDs.

2016-09-27consensus_review

CAC consensus review; no change to policy statements; variation reformatted.

Policy Summary

PayerCapital Bluecross

PolicyProsthetics and Accessories

Policy CodePolicy MP 6.018

Change TypeRetired (11/10/2023)content revisions and policy moves

Effective DateRETIRED 12/1/2024

Next Review DateN/A

Key ActionConsult the member's benefit plan or contact Capital Blue Cross to determine preauthorization requirements.

SourceLink

On This Page

Specific codes do not apply (no specific codes listed in the update).

ContextNoted in policy history alongside multiple administrative and consensus reviews.

Billing Rule

Cost-effectiveness and Replacement Thresholds

Coverage is limited to the most cost-effective, medically necessary device. Replacement is allowed when medically necessary due to a change in the member's physiological condition, irreparable damage to the device, or when repair costs exceed 60% of the cost of replacement. Replacement of devices dispensed prior to the procedure that necessitates the device is not covered. Replacement of lost or stolen devices is not covered within the expected useful life of the item (except where specific plan variations, e.g., CHIP, allow otherwise).

Replacement covered when: change in physiological condition; irreparable device damage; repair cost > 60% of replacement.
Devices dispensed prior to the procedure that will necessitate the device are not covered.
Lost or stolen devices not covered within expected useful life (plan variations may apply, e.g., CHIP allows identical replacement).

Documentation Required

Prescription and Documentation

The policy requires that prosthetic devices be prescribed by a physician and that documentation support the medical necessity — specifically that the device replaces all or part of an absent internal body organ or replaces function of a permanently inoperative or malfunctioning body part. The provided excerpts do not include additional specific documentation elements or explicit denial triggers.

Device must be prescribed by a physician.
Documentation must support replacement of an absent internal organ or function of a permanently inoperative/malfunctioning body part.
No explicit denial triggers are described in the provided excerpts.

Relation to ADLsFunctional mobility supports completion of basic activities of daily living and other tasks.

Permanently Inoperative — inv-22

DefinitionPermanently inoperative criteria are met when the medical record, including the judgment of the attending physician, indicates the condition will be of long and indefinite duration.

DocumentationRequires medical record evidence and attending physician judgment to establish long and indefinite duration.

ImplicationSupports coverage when a prosthetic replaces function of a permanently inoperative body part.

Reconstructive Surgery — inv-23

DefinitionReconstructive Surgery is a procedure performed to improve or correct a functional impairment, restore a bodily function, or correct a deformity resulting from birth defect or accidental injury.

ExclusionPsychological consequences alone do not qualify surgery as reconstructive in the absence of bodily functional impairment.

Coverage relevanceDistinguishes reconstructive procedures (which may make related prosthetics medically necessary) from purely cosmetic procedures.

MyoPro orthotic considered investigational — inv-24

StatusMyoPro orthotic is considered investigational (not medically necessary).

Effective date noted in historyDesignation added 1/9/19 per policy minor review.

ReasoningInvestigational designation due to insufficient evidence to support health outcomes or benefits (as stated in policy excerpts).

Accepted medically necessary reasons for wigs — inv-25

Accepted indicationsAlopecia areata, alopecia totalis, and alopecia universalis are accepted medically necessary reasons for wigs.

Addition dateThis indication was added 2/1/2022 per policy history.

Policy movementRelated breast prosthetics content was moved into MP 1.103 on the same 2/1/2022 update.

2017-11-28consensus_review

CAC consensus review; policy statements unchanged and references updated; Medicare variations removed effective 2018-01-01.

2018-05-08minor_review

Criteria added for prosthetics bras and for wigs; names revised for upper and lower limb prostheses and references updated.

2019-01-09minor_review

Criteria added stating that the MyoPro orthotic is considered investigational.

2020-01-09consensus_review

Consensus review; no change to policy statements and references updated.

2020-12-28consensus_review

Consensus review; policy statement unchanged and references updated.

2022-02-01minor_review

Breast prosthetics moved into MP 1.103; several incontinence sections consolidated; alopecia areata/totalis/universalis added as medically necessary reasons for wigs.

2023-11-10retirementLatest

Policy MP 6.018 was retired.

2024-12-01status_note

Policy status line shows RETIRED effective 12/1/2024.