Notification



Notification Issue Date:



Claim Payment Policy


Title:Repair or Replacement of an External Prosthetic Device

Policy #:05.00.45k

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

The repair or replacement of an external prosthetic device, supplies, or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when the external prosthetic device itself is covered under the individual's medical benefits and all of the following requirements for a repair or replacement are met.

Coverage of the repair or replacement of prosthetic devices and associated supplies and components (parts) may vary by product and/or group contract. Therefore, individual member benefits must be verified.

REPAIR

The repair of an external prosthetic device or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:
  • The prosthetic device does not function properly.
  • The device is not under a manufacturer's warranty.
  • The repair of the device is covered under the individual's medical benefits.

Please note: As some benefit contracts limit or exclude the repair of certain covered external prosthetic devices, individual member benefits must be verified.
  • The cost to repair the device or its components (parts) is less than the cost to replace it and is justified based on the useful life of the external prosthetic device as determined by the manufacturer.
  • The continued use of the device remains medically necessary and appropriate for the individual's condition.

The labor associated with the repair of an external prosthetic device is covered and eligible for separate reimbursement consideration and is reported using the applicable Healthcare Common Procedure Coding System (HCPCS) Level II code (refer to the Coding Table below).

REPLACEMENT

The replacement of a previously approved external prosthetic device or one or more of its components (parts) or supplies is covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:
  • The replacement device is covered under the individual's medical benefits.
    Please note: As some benefit contracts limit or exclude the replacement of certain covered external prosthetic devices, individual member benefits must be verified.
  • The replacement device is provided by an eligible ancillary provider.
  • The continued use of the device remains medically necessary for the individual and appropriate for the individual's condition.
  • The replacement is not an additional device (e.g., for use when traveling or for an additional residence).
  • The replacement is equivalent to a previously approved external prosthetic device/component.
  • The device itself is not under a manufacturer's warranty. However, the replacement of a supply to a covered external prosthetic device is covered.
  • The replacement device is for an individual who has either one of the following:
    • A change in condition that impacts the fit or function of the device and, therefore, requires its replacement (e.g., growth)
    • A device that does not function properly and has reached or exceeded its useful lifetime duration as determined by the manufacturer

The Company may determine the reasonable useful lifetime of a specific external prosthetic device based on the manufacturer's recommendation or the Food and Drug Administration (FDA)--approved labeling.

In the absence of manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific external prosthetic device, but is generally not less than five years. Replacement due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

Requests for a different type of an external prosthetic device or one or more of its components (parts) due to a change in medical and/or functional status, such that the prosthesis can no longer meet the individual’s needs for control, durability (maintenance), function (speed, work capability), and usability are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the new type of prosthesis requested.

NONCOVERED REPAIR OR REPLACEMENT

The repair or replacement of an external prosthetic device or one or more of its components (parts) is considered noncovered and not eligible for reimbursement consideration by the Company in each of the following circumstances:
  • The device itself is a benefit exclusion.
  • The request is for a visual prosthetic device (i.e., medically necessary glasses or contact lenses covered under the individual's medical benefit), which is not a benefit for most products of the Company. However, this repair or replacement statement of noncoverage does not apply to an ocular prosthesis, which is an artificial eye that replaces a missing eye due to congenital anomaly, disease, surgical removal (enucleation), or trauma.
  • The request is for a technologically advanced or newly released upgrade to an original device that still functions properly and/or there is no significant change in the individual's condition.
  • The device or one or more of its components (parts) is under a manufacturer's warranty. In this case, it is the individual's responsibility to arrange the repair or replacement of an external prosthetic device with the manufacturer while it is under warranty.
  • The request is solely being made to allow or enhance an individual's leisure, recreational activity, appearance, or athletic performance.
  • The request is due to the abuse or loss of the device.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation.

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

The repair or replacement of external prosthetic devices and associated components (parts), accessories, and associated supplies is reported using the specific repair or replacement Healthcare Common Procedure Coding System (HCPCS) procedure code corresponding to the item, when available. The labor related to the repair of external prosthetic devices is reported using the applicable HCPCS procedure code(s).

This policy addresses the repair or replacement of external prosthetic devices and associated components (parts) and supplies in general. When there is a policy addressing a specific type of external prosthetic device or associated component (part) or supply, the information in the specific policy supersedes this general policy.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the repair or replacement of external prosthetic devices and associated components (parts), accessories, and supplies is covered under the medical benefits of most of the Company's products. Coverage and reimbursement for the repair or replacement of external prosthetic devices vary by product and/or group contract. Therefore, individual member benefits must be verified.

Description

A prosthesis is a device that replaces all or part of an absent body organ, including contiguous tissue, or the function of a permanently inoperative or malfunctioning body organ. An external prosthetic device is a prosthesis that is worn on or external to the body such as, but not limited to, an artificial limb.

A supply or component (part) of an external prosthetic device is one that is necessary for the essential functioning of the external prosthetic device in relation to the individual's condition.

The repair of an external prosthetic device or component is the restoration of the device or one or more of its components (parts) to correct problems due to wear or damage.

The replacement of an external prosthetic device is the removal and substitution of the device or one or more of its components (parts) or supplies that are necessary for its proper functioning.
References


Company Benefit Contracts.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 20 – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). 10.1.3 - Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes.) [CMS Web site]. 05/26/06. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf. Accessed September 22, 2017.

New Jersey (NJ) Legislature. P.L. 2007, Chapter 345. Senate No. 502. Requires health benefits coverage by health insurers and SHBP for orthotic and prosthetic appliances and provides reimbursement. [NJ State Legislature Web site]. 01/13/08. Available at:
http://www.njleg.state.nj.us/2006/Bills/AL07/345_.PDF. Accessed September 22, 2017.

New Jersey Permanent Statutes. Title 17. Ch 48. 6b: Benefits for reconstructive breast surgery. [New Jersey Legislature Web site]. Original: 1983 (Amended: 1997). Available at:
http://lis.njleg.state.nj.us/cgi-bin/om_isapi.dll?clientID=212387&Depth=2&TD=WRAP&advquery=Benefits%20for%20reconstructive%20breast%20surgery.&depth=4&expandheadings=on&headingswithhits=on&hitsperheading=on&infobase=statutes.nfo&rank=&record={6C82}&softpage=Doc_Frame_PG42&wordsaroundhits=2&x=0&y=0&zz Accessed September 22, 2017.

Noridian Health Care Solutions, LLC. Local Coverage Article. Facial Prostheses - Policy Article (A52463). Revised Effective 01/01/2017. Original effective: 10/01/2015. https://med.noridianmedicare.com/documents/2230703/7218263/Facial+Prostheses. Accessed October 19, 2017.

Social Security Administration (SSA), The. Compilation of the Social Security Laws. Replacement of prosthetic devices and parts. SEC. 1834. [42 U.S.C. 1395m] 1834 - (h) (1) (g). [SSA Web site]. 06/28/06. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1834.htm#fnr147. Accessed September 22, 2017.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



Please note:
When there is no specific HCPCS code for the repair or replacement of an external prosthetic device, the applicable HCPCS code for the specific device should be reported with the appropriate modifier. (Refer below for specific information regarding this modifier.)

THE FOLLOWING LIST INCLUDES ONLY THOSE HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES WITH REPAIR OR REPLACEMENT IN THE NARRATIVE:

A4363 Ostomy clamp, any type, replacement only, each

A5113 Leg strap; latex, replacement only, per set

A5114 Leg strap; foam or fabric, replacement only, per set

D5926 Nasal prosthesis, replacement

D5927 Auricular prosthesis, replacement

D5928 Orbital prosthesis, replacement

D5929 Facial prosthesis, replacement

L5700 Replacement, socket, below knee, molded to patient model

L5701 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model

L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model

L5703 Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

L5971 All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

L6884 Replacement docket, above elbow/elbow disarticulation, molded to patient model, for with or without external power.

L6885 Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power

L6915 Hand restoration (shading and measurements included), replacement glove for above

L7367 Lithium ion battery, rechargeable, replacement

L7368 Lithium ion battery charger, replacement only

L7510 Repair of prosthetic device, repair or replace minor parts

L7520: Repair prosthetic device, labor component, per 15 minutes

L8048 Unspecified maxillofacial prosthesis, by report, provided by a nonphysician

L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician

L8505 Artificial larynx replacement battery/accessory, any type

L8511 Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each

L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10

L8513 Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each

L8514 Tracheoesophageal puncture dilator, replacement only, each

L8615 Headset/headpiece for use with cochlear implant device, replacement

L8616 Microphone for use with cochlear implant device, replacement

L8617 Transmitting coil for use with cochlear implant device, replacement

L8618 Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement

L8619 Cochlear implant, external speech processor and controller, integrated system, replacement

L8621 Zinc air battery for use with cochlear implant device, replacement, each

L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each

L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

L8624 Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each

L8625 External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each

L8627 Cochlear implant, external speech processor, component, replacement

L8628 Cochlear implant, external controller component, replacement

L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement

L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each

L8693 Auditory osseointegrated device abutment, any length, replacement only

L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each

L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only

Q0479 Power module for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0496 Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

Q0506 Battery, Lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only

V5014 Repair/modification of a hearing aid



Revenue Code Number(s)

N/A


Misc Code

Modifiers:

WHEN THERE IS NO SPECIFIC HCPCS CODE FOR THE REPAIR OR REPLACEMENT OF AN EXTERNAL PROSTHETIC DEVICE, THE FOLLOWING MODIFIER IS APPENDED TO THE HCPCS CODE FOR THE DEVICE ITSELF:

RA Replacement of a DME, Orthotic or Prosthetic item

RB Replacement of a part of a DME, Orthotic or Prosthetic item furnished as part of a repair



Coding and Billing Requirements


Cross References


Policy History

05.00.45k:
01/01/2018This policy has been identified for the HCPCS code update, effective 01/01/2018.

The following HCPCS codes have been added to this policy:

L8625 External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each

L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each

The following HCPCS code narratives have been revised in this policy:

From: L8618 Transmitter cable for use with cochlear implant device, replacement
To: L8618 Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement

From: L8624 Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each
To: L8624 Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each

From: L8691 Auditory osseointegrated device, external sound processor, replacement
To: L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each



05.00.45j
12/15/2017This version of the policy will become effective 12/15/2017. This policy has been updated to communicate the Company’s continuing position on repair or replacement of an external prosthetic device and supplies.

The following criteria has been added to this policy:

REPAIR
  • The prosthetic device does not function properly.

The following HCPCS code has been added to this policy:
    L8048 Unspecified maxillofacial prosthesis, by report, provided by a nonphysician

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.