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Repair or Replacement of an External Prosthetic Device
MA05.063d

Policy

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.

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 device is covered by Medicare.
  • The repair of the device is covered under the individual's medical benefits.
  • 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 by Medicare.
  • 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 (eg, 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.

Replacement of a device is covered in cases of loss, or irreparable damage or wear, and when required because of a change in the individual's condition.

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, therefore, is not eligible for reimbursement consideration by the Company, in each of the following circumstances:
  • The device itself is not covered.
  • 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.

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 Medicare’s coverage determination for repair or replacement of an external prosthetic device and supplies. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, repair or replacement of an external prosthetic device and supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

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


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.

Evidence of Coverage.

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.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
See Attachment A
Revenue Code Number(s)
N/A

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

Policy History

MA05.063d
04/01/2026​​This policy has been identified for the HCPCS code update, effective 04/01/2026.

The following HCPCS codes have been added to Attachment A of this policy:

A8006 Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only

L5992 All lower extremity prosthesis, foot shell for modular foot/non-solid ankle cushion heel (sach) replacement only​  

MA05.063c
01/01/2018
    ​This policy has been identified for the HCPCS code update, effective 01/01/2018.

    The following HCPCS codes have been added to attachment A of 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 attachment A of 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


MA05.063b
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 intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

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

MA05.063a
09/28/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on repair or replacement of an external prosthetic device and supplies.
01/01/2016This version of the policy will become effective 01/01/2016.

The following HCPCS code, L8621, has been revised in Attachment A, of this policy.

MA05.063
08/19/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on repair or replacement of an external prosthetic device and supplies.
01/01/2015This is a new policy.
Note: On 12/16/2014 this Notification was revised to include 1/1/2015 HCPCS coding update. Attachment A of this policy was updated as follows:
  • Code L7367 has a revised narrative.
4/1/2026
5/14/2026
MA05.063
Claim Payment Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.