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.
Prosthetic 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:
Surgical Prostheses:
Artificial joints necessary for joint repair and reconstructive surgery
Breasts, internal and external (including a surgical brassiere), for post-mastectomy reconstruction
Cardiac pacemakers, atomic or electronic
Intra-ocular lenses (Conventional Lenses only, NOT Presbyopia-Correcting Intraocular Lenses*)
Maxillofacial and intra-ocular lenses* as replacement of either surgically removed or congenitally absent crystalline lenses of the eye
Nonsurgical Prostheses:
Artificial eyes
Artificial limbs replacing all or part of absent extremities
Speech aids (does not include computers; hardware or software)
Urinary collection and retention systems (Foley catheters, tubes, bags, etc.) in cases of permanent urinary incontinence.
Dentures replacing teeth or structures directly supporting teeth (Note: Dentures are covered if natural teeth are removed after radiation therapy. This is a one time coverage. [added 5-9-2002]
Hairpieces for male-pattern alopecia
Hearing aids
Implants for cosmetic purposes
Electrical continence aids, either anal or urethral
Penile prostheses
Wigs
Presbyopia-Correcting Intraocular Lenses*
*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.
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.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Additions: endoskeletal knee-shin system code range
L5858
Addition to lower extremity prosthesis, endoskeletal knee shin system. microprocessor control feature, stance phase only, includes electronic sensor(s), any type
L5971
All lower extremity prosthesis, solid ankel cushion heel (sach) foot, replacement only
L5973
Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion (New 1-1-2010)
Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)
This is not an all-inclusive list of non-covered procedure codes.
All codes billed for this procedure are considered non-covered and not eligible for coverage.
Non-Covered Codes
Code Number
Description
CPT-4
54400, 54401, 54405
Penile prosthetic code range
54406
Removal of all componets of a multi-componet, inflatable penile prosthesis without replacement of prosthesis
54408
Repair of componet(s) of a multi-componet, inflatable penile prosthesis
54410
Removal and replacement of all componet(s) of a multi-componet, inflatable penile prosthesis at the same operative session
54411
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
54415
Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis
54416
Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
54417
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
ICD-9 Procedure
95.48
Fitting of hearing aid
ICD-9 Diagnosis
HCPCS
A9282
Wig, any type, each
L5703
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach), foot, replacement only
L7900
Male vacum erection system
S0618
Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
V2788
Presbyopia correcting function of intraocular lens (added 9-28-2006)
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