Upper Extremity Prosthetic Devices (Ohio)
This Ohio-specific medical policy governs coverage and medical necessity criteria for upper extremity prostheses, including myoelectric devices and bone-anchored implants, and applies to requests evaluated under Ohio Administrative Code.
Revised coverage criteria for upper extremity prosthetic for amputations and upper extremity myoelectric prosthetic hand, partial hand, or artificial digit(s) for amputations below the wrist.
Replaced criterion requiring evaluation by a healthcare professional under supervision with language allowing evaluation by a physician, health care professional, or other licensed practitioner acting within scope of practice, with appropriate prosthetic qualifications and training, annually.
Added medical records documentation language specifying that documentation may be required to assess clinical criteria, must support medical necessity, and be available upon request.
Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and does not guarantee coverage.
The patient's medical record must contain documentation that fully supports medical necessity, including relevant history, physical exam, and pertinent test results; documentation should be legible and available upon request.
Revised description for HCPCS codes L6028 and L7406.
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