Coverage Policies

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Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 05/01/2009 Title: Orthotic Devices & Orthotic Services
Revision Date: 07/01/2018 Document: BI217:00
CPT Code(s): Refer to chart below
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1)    “Orthotic devices” and “orthotic services” are covered for QualChoice’s fully-insured plans in compliance with Arkansas law (Arkansas Code Annotated § 23-99-403 et seq. see Background for details of the Law) and as reflected in your Evidence of Coverage and Benefits Summary. Per Arkansas law “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet the criteria for orthotics and are therefore not covered.

2)    QualChoice does not cover replacement of an orthotic device or associated orthotic services more frequently than one (1) time every three (3) years unless medically necessary or indicated by other coverage criteria under the QualChoice fully-insured plan. However, QualChoice will replace or repair an orthotic device if necessary due to anatomical changes or normal use, subject to co-payments, deductibles, and co-insurance as set out in your Benefits Summary.

3)    Shoe inserts and orthopedic shoes are generally not covered.  For diabetic shoes and inserts, see BI198: Diabetic Shoes and Shoe Inserts and BI039: Foot Care.

4)    Back braces are generally not covered unless there is documentation of spinal stenosis, scoliosis, and fracture of the spine or recovery following spinal surgery. In these situations, only certain specific types of back braces are covered. Evidence does not support the use of back braces for chronic back pain. Please refer to BI534: Back Braces.

5)    The Pre-authorization requests for orthotics require:

a)  Submission by the ordering provider office and not by the vendors AND

b)  Accompanying patient medical records such as provider clinic progress notes. c)  Information submitted on vendor request forms is not acceptable.


Medical Statement

1)    The following “orthotics devices” and “orthotic services,” including their fitting and repair, do not require pre-authorization:

a)    L1902, L1906 – Ankle orthotic

b)    L3260 – Surgical shoe

c)    L3650 – L3670 – Shoulder orthotic

d)    L3702, L3710, L3762 – Elbow orthotic

e)    L3806 – L3808 – Wrist-hand-finger orthotic

f)     L3908, L3912 – Wrist-hand orthotic

g)    L3917 – L3935 – Finger orthotic

h)   L3980 – L3984, L3995 – Upper extremity fracture orthotic

i)     L4000 – L4210 – Repair/replacement items

j)      L4350 – L4398– Other lower extremity supports

2)    The following services require pre-authorization:

a)    97760, 97763 – Orthotic Management/training and check-out

3)    For diabetic shoes and inserts, fitting, and modification, please see the following BI’s: BI198: Diabetic Shoes and Shoe Inserts, and BI039: Foot Care.

4)    For knee orthotics and their additions, please see BI553: Knee Braces.

5)    Please see BI534: Back races for back braces and rib belts. In accordance with the definition of an ”orthotic device” under Arkansas law, QualChoice does not  cover the following orthotic devices:

a)    Back braces intended to prevent injury or to permit especially heavy lifting.

b)    Any brace or support intended to enhance function past normal, such as to enable running a marathon or operating a jack-hammer.

c)    Any device that is not prescribed by one of:

(1)  A licensed doctor of medicine,

(2)  A licensed doctor of osteopathy,

(3)  A licensed doctor of podiatric medicine.

d)    Any device that is not provided by one of the above practitioners or by :

(1)  A licensed orthotist

(2)  A licensed prosthetist.

(3)  A licensed Occupational Therapist.

6)    QualChoice does not cover replacement of an orthotic device or associated orthotic services more frequently than one (1) time every three (3) years unless medically necessary or indicated by other coverage criteria under the QualChoice fully-insured plan.   However, QualChoice will replace or repair an orthotic device if necessary due to anatomical changes or normal use, for example, in the case of rapid growth of a child means that an orthotic device of a different size is appropriate.

7)      Shoe inserts and orthopedic shoes are generally not covered.

8)      Except as noted above, “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet the Arkansas law criteria for orthotics and are therefore not covered.  All other codes (for customized orthotics) require pre-authorization.  

Codes Used In This BI: L0112 L0113 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190 L0200 L1610 L1620 L1630 L1640 L1650 L1652 L1660 L1680 L1685 L1686 L1690 L1700 L1710 L1720 L1730 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L1990 L2000 L2005 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2232 L2240 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2350 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2861 L2999 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 L3650 L3660 L3670 L3671 L3674 L3675 L3677 L3702 L3710 L3720 L3730 L3740 L3760 L3762 L3763 L3764 L3765 L3766 L3806 L3807 L3808 L3891 L3900 L3901 L3904 L3905 L3906 L3908 L3912 L3913 L3915 L3917 L3919 L3921 L3923 L3925 L3927 L3929 L3931 L3933 L3935 L3956 L3960 L3961 L3962 L3964 L3964 L3964 L3965 L3965 L3965 L3966 L3966 L3966 L3967 L3968 L3968 L3968 L3969 L3969 L3969 L3970 L3971 L3972 L3973 L3974 L3975 L3976 L3977 L3978 L3980 L3982 L3984 L3995 L3999 L4000 L4002 L4010 L4020 L4030 L4040 L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4370 L4380 L4386 L4392 L4394 L4396 L4398 L4631 97760 97762 97763

Limits

1)    No appliance or device will be covered as an orthotic device and no service will be covered as an orthotic service if it does not meet the definitions of orthotic device and orthotic service under Arkansas law and as set forth in the Back Ground statement of this policy.

2)    Examples of devices that would not be covered for this reason (unless specified in member coverage document),  includes but is not limited to the following examples:

a)    Prophylactic knee braces have not been shown to be effective and are not recommended for use. Functional knee braces do offer a useful adjunct to the rehabilitation of knee ligament injuries.

b)    Services or equipment that are more costly when QualChoice determines that less costly, equally effective services or equipment are available.

c)    Materials or services covered under a manufacturer’s warranty.

d)    Procedures, services or supplies rendered in the course of providing a non-covered service, such as gender-change surgery.

e)    Non-covered items would also include:

i)     Any of the following items that are specifically excluded under Arkansas law as being required to be covered:

(1)  Arch supports,

(2)  Jobst stockings,

(3)  hearing aids (refer to BI049 or BI264),

(4)  Ace bandages,

(5)  Urethane calcaneal brace,

(6)  Cast shoes (refer to BI 198 for foot orthotics coverage).

ii)    Repairs required due to abuse or neglect of the device.

iii)   Dentures are not covered.


Background

In order for a device to be an “orthotic device” as defined by Arkansas law and covered under QualChoice’s fully-insured plans, the device must meet all of the following three (3) requirements:

1)    The external device is:

a)    Intended to restore physiological function or cosmesis to a patient; and

b)    Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with the delivery of the device to the patient.

2)    The device must be prescribed by one of:

                                                    i.     A licensed doctor of medicine,

                                                   ii.     A licensed doctor of osteopathy,

                                                 iii.     A licensed doctor of podiatric medicine.

3)    The device must be provided by one of:

                                                    i.     A licensed doctor of medicine,

                                                   ii.     A licensed doctor of osteopathy,

                                                 iii.     A licensed doctor of podiatric medicine

                                                 iv.     A licensed orthodontist

                                                  v.     A licensed prosthetist.

An orthotic device does not include:

·       A cane

·       A crutch

·       A corset

·       A dental appliance

·       An elastic hose

·       An elastic support

·       A fabric support

·       A generic arch support

·       A low-temperature plastic splint

·       A soft cervical collar

·       A truss

·       Any similar device meeting both of these requirements:

                                                    i.          It is carried in stock and sold without therapeutic modification by:

a.     A corset shop

b.     A department store

c.     A drug store

d.     A surgical supply facility

e.     A similar retail entity; and

                                                   ii.          It has no significant impact on the neuromuscular, musculoskeletal or neuromusculoskeletal functions of the body.

1)    In accordance with the above definition, the following are examples of devices not considered to be orthotic devices:

a)    Fixation devices for fractures, sprains or other acute injuries.

                                          i.     Such devices may be covered under other provisions of your coverage document.

                                         ii.     The intent is to prevent injury rather than to restore physiologic function.

b)    Any brace or support intended to enhance function past normal, such as to enable running a marathon or operating a jack-hammer.

                                          i.     The intent is to enhance function above normal, rather than to restore physiologic function.

                                         ii.     For such purposes, braces and supports are not covered under this plan.

c)     Molded shoes, shoe inserts and “foot orthotics” is more frequently for comfort than for restoration of physiologic function.

                                          i.     Used for comfort, not for restoration of physiologic function, they are not covered.

                                         ii.     When used for patients with diabetes to prevent or ameliorate foot damage, they may be covered (see policy BI 198).

                                       iii.     If prescribed and dispensed to restore physiologic function, that purpose must be clearly delineated in a preauthorization request for consideration by QualChoice.

d)    Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.


Reference

Arkansas Code Annotated § 23-99-403 et seq.

 

Addendum: 

 

1.     Effective 01/01/2017: Clarifying language was added that, according to AR state law, off-the-shelf products do not meet the definition of orthotic devices. Clarification was also added for when back braces are and are not covered.

 

2.     Effective 06/01/2017: Added L3995 to upper extremity fracture orthotic code to be covered without prior authorization. For back braces added reference to the new policy BI534 on Back Braces.  Added clarifying verbiage that requests for orthotics will need to be submitted by ordering provider office along with provider’s clinic progress notes. Requests from vendors or on vendor request forms will not be accepted.

 

3.     Effective 07/01/2017; Made reference to BI198 Diabetic Shoes and Shoe inserts and BI039 Foot Care

 

4.     Effective 11/01/2017:  Made reference to BI534 on back braces for rib belts.  Made reference to BI553 on Knee braces.

 

5.     Effective 02/01/2018: Deleted outdated or non-pertinent codes.

 


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

The Federal Employees Health Benefit Program (FEHBP) has different coverage. Please see refer to your policy brochure.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.