CurrentNew Mexico Health Care AuthorityPolicy N/A

Coverage Criteria for Prosthetic and Custom Orthotic Devices

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Directs New Mexico MCOs on updated coverage and reimbursement for prosthetic and custom orthotic devices for Medicaid-eligible recipients, effective July 1, 2024.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyCoverage Criteria for Prosthetic and Custom Orthotic Devices

Policy CodePolicy N/A

Change TypeCoverage updates and prior-approval clarification

Effective DateJul 1, 2024

Next Review Date

Key ActionObtain prior approval for prosthetic devices unless the prosthetic limb is attached immediately following surgery for a traumatic injury while the recipient is an inpatient.

SourceLink

POLICY UPDATE CHANGES

All prosthetic devices will continue to require prior approval except prosthetic limbs attached immediately following surgery for traumatic injuries while the recipient is a hospital inpatient.

Covered services include formulation, fabrication, repair, and replacement necessary for physical functioning, including running, bicycling, and swimming.

Replacement is covered when there is a change in patient need, device condition, or when repairs would cost more than 60% of replacement cost.

MCOs will reimburse providers meeting requirements for dates of service on or after July 1, 2024.

2024-07-01effective date for coverage updates

60%repair vs replacement cost threshold

prosthetic limbs exception

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Coverage Criteria for Prosthetic and Custom Orthotic Devices

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Directs New Mexico MCOs on updated coverage and reimbursement for prosthetic and custom orthotic devices for Medicaid-eligible recipients, effective July 1, 2024.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyCoverage Criteria for Prosthetic and Custom Orthotic Devices

Policy CodePolicy N/A

Change TypeCoverage updates and prior-approval clarification

Effective DateJul 1, 2024

Next Review Date

Key ActionObtain prior approval for prosthetic devices unless the prosthetic limb is attached immediately following surgery for a traumatic injury while the recipient is an inpatient.

SourceLink

POLICY UPDATE CHANGES

All prosthetic devices will continue to require prior approval except prosthetic limbs attached immediately following surgery for traumatic injuries while the recipient is a hospital inpatient.

Covered services include formulation, fabrication, repair, and replacement necessary for physical functioning, including running, bicycling, and swimming.

Replacement is covered when there is a change in patient need, device condition, or when repairs would cost more than 60% of replacement cost.

MCOs will reimburse providers meeting requirements for dates of service on or after July 1, 2024.

2024-07-01effective date for coverage updates

60%repair vs replacement cost threshold

prosthetic limbs exception

Coverage Criteria for Prosthetic and Custom Orthotic Devices

Covered when ALL of the following are met:

General medical necessity: Prosthetic or custom orthotic device is medically necessary to treat an illness or injury or to improve functioning of a specific body part.

Includes formulation, fabrication, repair, and replacement necessary for physical functioning (e.g., running, bicycling, swimming).

Prior approval obtained unless the device is a prosthetic limb attached immediately following surgery for traumatic injuries while the recipient is a hospital inpatient.

Replacement justification: Replacement is justified by a change in the patient's need OR a change in the condition of the device (or a piece of the device) OR when repairs would cost more than 60% of the cost of a replacement device or part.60% repair cost threshold

No additional exclusions are specified in this Letter of Direction beyond the general coverage rules for prosthetic and custom orthotic devices provided by HCA. The document does not list any separate or explicit exclusion items for this line of direction.

The policy does not enumerate specific conditions or situations labeled as not medically necessary. Coverage is governed by the requirement that devices meet medical necessity criteria and, where applicable, obtain prior approval; absence of those conditions may affect coverage but no further explicit "not medically necessary" exclusions are listed.

Repair vs Replacement and Coding Implications

Repair cost threshold — replacement justification

Repair vs replacement thresholdRepairs that would cost more than 60% of the cost of a replacement device or part justify coverage of replacement.

Replacement justificationsReplacement is covered when there is a change in the patient’s need or a change in the condition of the device or device component.

Scope of cost comparisonThreshold applies to repair cost compared to the cost of a replacement device or part (60% benchmark).

Provider Requirements and Prior Authorization

Prior Authorization

Prior approval required for prosthetic devices

Prior approval must be obtained for all prosthetic devices. The only exception is for prosthetic limbs that are attached immediately following surgery for traumatic injuries while the recipient is a hospital inpatient.

Step Therapy

No step therapy requirements specified

The policy does not impose any step therapy requirements for prosthetic or custom orthotic devices.

Documentation Required

Medical necessity and replacement documentation

Background and Purpose

Medically necessary prosthetic and custom orthotic devices are intended to restore or improve physical functioning following an illness or injury. The LOD specifies that such devices are covered when required to meet special physical needs of Medicaid-eligible recipients for treatment of an illness or injury or to improve the functioning of a specific body part, and that covered services include formulation, fabrication, repair, and replacement necessary for physical activities such as running, bicycling, and swimming.

Definitions and Scope

Medically necessary prosthetics or custom orthotic devices — scope of coverage

Covered devices — definitionMedically necessary prosthetic and custom orthotic devices to meet special physical needs of Medicaid-eligible recipients for treatment of an illness, injury, or to improve functioning of a specific body part.

Included servicesFormulation, fabrication, repair, and replacement necessary for physical functioning (explicitly includes activities such as running, bicycling, and swimming).

Prior approval requirementPrior approval is required for all prosthetic devices except prosthetic limbs attached immediately following surgery for traumatic injuries while the recipient is a hospital inpatient.

Replacement criteriaReplacements are covered for change in patient need, change in device condition, or when repair costs exceed 60% of replacement cost.