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Prosthetics are artificial substitutes which replace all or part of a body organ, or replace all or part of the function of a permanently inoperative, absent, or malfunctioning body part.
A prosthetic sheath may be used alone, placed directly on an amputated limb, or under a prosthetic sock. These garments wick away moisture and help prevent skin breakdown.
POLICYProsthetic appliances are considered medically necessary when prescribed by a qualified provider to replace absent or nonfunctioning parts of the human body by an artificial substitute, whether surgically implanted or worn as an anatomic supplement. Prosthetic appliances include:
The following are non-covered prosthetic devices:
*Providers may bill the patient the additional expenses associated with insertion of accommodative lenses if the patient signs a waiver specific to non-coverage of accommodative lenses for the specific date of service the lens is inserted. An example would be crystalens or other accommadative lenses such as the AcySof ReSTOR Apodized Diffractive Optic Posterior Chamber Intraocular Lens to correct presbyopia. In addition, any charges for additional treatments, services, supplies or other associated charges required to insert, adjust or follow-up a presbyopia-correcting intraocular lens (IOL) following removal of a cataract that exceed the physician charges for services and supplies for the insertion and adjustment of a conventional IOL are also not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
No benefits will be available for fitting or adjustments as this is included in the allowable charge for the prosthetic appliance.
Benefits will be provided for repair or replacement of the prosthetic appliance after a reasonable length of time. This time period will be determined by the company.
Benefits based on the allowable charge for standard equipment will be provided toward any deluxe equipment when selected by the member solely for the member's comfort or convenience.
Benefits for deluxe equipment based on the allowable charge for deluxe equipment will only be provided when documented to be medically necessary.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY11/1997: Approved by Medical Policy Advisory Committee (MPAC)
9/19/2000: Speech aids (does not include computers; hardware or software) added
2/28/2002: Prior Authorization and Managed Care Requirements deleted
3/13/2002: New 2002 codes added, CPT code 54406, 54408, 54410, 54411, 54415, 54416, 54417 added, HCPCS K0542 added
5/2/2002: Type of Service and Place of Service deleted
5/9/2002: Denture coverage "exception" added
12/11/2002: CPT 92330 , 92335 , 92393 added
3/13/2003: Code Reference section updated, HCPCS K0556, K0558, K0559, L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0474, L0476, L0478, L0480, L0482, L0484, L0486, L0488, L0490, L1652, L1836, L1901, L3651, L3652, L3701, L3762, L3909, L3911, L4386, L5781, L5782, L5848, L5995, L6025, L6638, L6646, L6647, L6648, added, HCPCS range L5000-L7499, L8000-L8670, V2623-V2629 listed separately
7/27/2005: Policy section statement "Penile prostheses in men suffering impotency resulting from disease or injury" changed to "Penile prostheses," Code Reference section updated, non-covered codes table added, CPT code 54406, 54408, 54410, 54411, 54415, 54416, 54417 moved from covered to non-covered codes, CPT code 54400, 54401, 54405, 92590, 92591, 92592, 92593, 92594, 92595 added non-covered codes, CPT code 21076, 21077, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087, 21088, 21089, 92597, 92605, 92607, 92608 added covered codes, ICD-9 procedure code 95.48 added non-covered codes, ICD-9 procedure code 95.34 added covered codes, HCPCS L7900, S0618, S8095, V5008, V5010, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5095, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5266, V5267, V5268, V5269, V5270, V5271, V5272, V5273, V5274, V5275, V5298, V5299 added non-covered codes, HCPCS L8230 moved from covered to non-covered, HCPCS D5911, D5912, D5913, D5914, D5915, D5916, D5919, D5922, D5923, D5924, D5925, D5926, D5927, D5928, D5929, D5931, D5932, D5933, D5934, D5935, D5936, D5937, D5951, D5952, D5953, D5954, D5955, D5958, D5959, D5960, D5982, D5983, D5984, D5985, D5986, D5987, D5988, D5999, L5673, L5679, L5681, L5683, L7367, L7500, L7510, L7520, L8511, L8512, L8513, L8514, L8631, L8699, Q1001, Q1002, Q1003, Q1004, Q1005, V2630, V2631, V2632 added covered codes, HCPCS L5685, L5856, L5857, L6694, L6695, L6696, L6697, L6698, L7181, L8515 with effective date 1/1/2005 added covered codes, HCPCS K0440-K0449, K0542, K0556, K0557, K0558, K0559, L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0474, L0476, L0478, L0480, L0482, L0484, L0486, L0488, L0490, L1652, L1836, L1901, L3651, L3652, L3701, L3762, L3909, L3911, L4386, L5660, L5662, L5663, L5664 deleted covered codes, HCPCS L5674, L5675, L5846, L5847, L5989, L8490 deletion date of 12/31/2004 added
11/16/2005: Code Reference section updated, HCPCS code K0670 added
3/13/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
4/19/2006: Policy reviewed, intraocular lens statement clarified
9/27/2006: Coding updated. ICD9 revisions added to policy
9/28/2006: Code reference section updated. CPT codes 66982, 66983, 666984 and V2788 added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
12/15/2009: Code Section revised with 2010 CPT4 and HCPCS revisions
06/21/2011: Added HCPCS code L7368 to the Covered Codes tabe.
12/31/2014: Added the following new 2015 HCPCS codes to the Code Reference section: L6026 and L7259. Revised the description of the following HCPCS code: L7367.
08/31/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes A6542 and A6543.
04/26/2016: Policy Guidelines updated to add medically necessary definition. Code Reference section updated to remove deleted HCPCS codes L6025, L7260, and L7261 from the Covered Codes table.
05/31/2016: Policy number L.1.04.401 added.
SOURCE(S)Blue Cross & Blue Shield Association policy #1.04.01
Hayes Medical Technology Directory
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
54400, 54401, 54405
Penile prosthetic code range
Removal of all componets of a multi-componet, inflatable penile prosthesis without replacement of prosthesis
Repair of componet(s) of a multi-componet, inflatable penile prosthesis
Removal and replacement of all componet(s) of a multi-componet, inflatable penile prosthesis at the same operative session
Removal and replacement of all componets of a multi-componet inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis
Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same time operative session, including irrigation and debridement of infected tissue
92590, 92591, 92592, 92593, 92594, 92595
Hearing aid examination and selection code range
Wig, any type, each
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach), foot, replacement only
Male vacum erection system
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
Presbyopia correcting function of intraocular lens
V5008, V5010, V5011, V5014, V5020, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5095, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5264, V5265, V5266, V5267, V5268, V5269, V5270, V5271, V5272, V5273, V5274, V5275, V5298, V5299
Hearing services code range
Fitting of hearing aid
F0DZ51Z, F0DZ52Z, F0DZ55Z, F0DZ5KZ, F0DZ5LZ, F0DZ5ZZ
Monaural or Binaural Hearing Aid Device Fitting using various Equipment
F0DZ51Z, F0DZ52Z, F0DZ55Z, F0DZ5KZ, F0DZ5LZ, F0DZ5ZZ
Assistive Listening Device, Device Fitting using various Equipment
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