California Code of Regulations
Title 22 - Social Security
Division 3 - Health Care Services
Subdivision 1 - California Medical Assistance Program
Chapter 3 - Health Care Services
Article 4 - Scope and Duration of Benefits
Section 51315 - Amount, Scope, Duration, Limitation and Prior Authorization of Benefits for Orthotic and Prosthetic Appliances and Services
Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Orthotic and prosthetic appliances and services, to the extent necessary for the restoration of function or replacement of a body part(s), or to support a weakened or deformed body member, are covered under the Medi-Cal program as follows:
(b) A written prescription signed by a licensed physician, a licensed podiatrist, a licensed dentist or a licensed non-physician medical practitioner, and clinical notes/medical professional records that document the medical necessity of the appliance or service, shall be maintained by the provider in the patient's medical record, pursuant to Section 51476. A copy of the written, signed prescription or the electronic image/data transmission prescription in accordance with Health and Safety Code, Section 11027 and documentation of medical necessity, as specified in subsection (c), shall accompany the request for prior authorization, which is required under the following circumstances:
(c) The prior authorization request for orthotic and prosthetic appliances and services shall be authorized when documentation includes the type of appliance or service; the medical diagnosis, and prognosis; an explanation of the purpose for the appliance or service; and substantiation that the criteria specified in subsection (c)(1) through (5) below, and the criteria specified in Section 51315.1 for orthotic appliances and services, or the criteria specified in Section 51315.2 for prosthetic appliances and services are met.
(d) Prior authorization of orthotic and prosthetic appliances and services shall not be granted for any of the following:
(e) Reimbursement for orthotic and prosthetic appliances and services shall be subject to the following:
1.
Amendment of subsection (a) filed 5-30-78; designated effective 7-1-78
(Register 78, No. 22). For prior history, see Register 77, No.
50.
2. Amendment of subsection (d) filed 1-16-80; effective
thirtieth day thereafter (Register 80, No. 3).
3. Amendment of
subsection (a) filed 11-7-86; effective thirtieth day thereafter (Register 86,
No. 45).
4. Change without regulatory effect of NOTE (Register 86,
No. 49).
5. Amendment of subsection (a) filed 5-25-89; operative
6-24-89 (Register 89, No. 21.)
6. Amendment of subsection (a) and
NOTE, designation and amendment of subsections (a)(1)(A) and (B), and new
subsections (a)(1) and (a)(2)-(a)(2)(B) filed 9-14-92; operative 10-14-92
(Register 92, No. 38).
7. Amendment of subsections (a)(2)-(a)(2)(B)
filed 3-24-93; operative 4-23-93 (Register 93, No. 13).
8. Change
without regulatory effect amending subsection (a)(2) and NOTE filed 3-8-94
pursuant to title 1, section
100, California Code of
Regulations (Register 94, No. 10).
9. Editorial correction
reinstating inadvertently omitted subsections (b)-(d)(2) (Register 97, No.
37).
10. Amendment of subsection (a), repealer of subsections
(a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as
new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed
7-17-2003 as an emergency; operative 7-17-2003 (Register 2003, No. 29). A
Certificate of Compliance must be transmitted to OAL by 1-13-2004 or emergency
language will be repealed by operation of law on the following
day.
11. Editorial correction of HISTORY 10 (Register 2003, No.
33).
12. Amendment of subsection (a), repealer of subsections
(a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as
new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed
1-14-2004 as an emergency; operative 1-14-2004 (Register 2004, No. 3). A
Certificate of Compliance must be transmitted to OAL by 7-12-2004 or emergency
language will be repealed by operation of law on the following
day.
13. Certificate of Compliance as to 1-14-2004 order, including
further amendment of subsections (a)-(a)(2), new subsections (e)-(f)(4) and
amendment of NOTE, transmitted to OAL 7-12-2004 and filed 8-12-2004 (Register
2004, No. 33).
14. Amendment of section heading, section and NOTE
filed 10-2-2015; operative 1-1-2016 (Register 2015, No.
40).
Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14103.7, 14105, 14105.21, 14132, 14132.10, 14132.765, 14133, 14133.1, 14133.3 and 14133.9, Welfare and Institutions Code.