Current through Vol. 42, No. 1, September 16, 2024
(a)
Coverage of prosthetics for non-expansion adults is limited to (1) home
dialysis equipment and supplies, (2) nerve stimulators, (3) external breast
prosthesis and support accessories, and (4) implantable devices inserted during
the course of a surgical procedure. Prosthetics prescribed by an appropriate
qualified provider and as specified in this section are covered items for
non-expansion adults. There is no coverage of orthotics for non-expansion
adults.
(1)
Home dialysis.
Equipment and supplies are covered items for members receiving home dialysis
treatments only.
(2)
Nerve
stimulators. Payment is made for transcutaneous nerve stimulators,
implanted peripheral nerve stimulators, and neuromuscular
stimulators.
(3)
Breast
prosthesis, bras, and prosthetic garments.
(A) Payment is limited to:
(i) One (1) prosthetic garment with
mastectomy form every twelve (12) months for use in the postoperative period
prior to a permanent breast prosthesis or as an alternative to a mastectomy bra
and breast prosthesis;
(ii) Two (2)
mastectomy bras per year; and
(iii)
One (1) silicone or equal breast prosthetic per side every twenty-four (24)
months; or
(iv) One (1) foam
prosthetic per side every six (6) months.
(B) Payment will not be made for both a
silicone and a foam prosthetic in the same twelve (12) month period.
(C) Breast prostheses, bras, and prosthetic
garments must be purchased from a Board Certified Mastectomy Fitter.
(D) A breast prosthesis can be replaced if:
(i) Lost;
(ii) Irreparable damaged (other than ordinary
wear and tear); or
(iii) The
member's medical condition necessitates a different type of item and the
physician provides a new prescription explaining the need for a different type
of prosthesis.
(E)
External breast prostheses are not covered after breast reconstruction is
performed except in instances where a woman with breast cancer receives
reconstructive surgery following a mastectomy, but the breast implant fails or
ruptures and circumstances are such that an implant replacement is not
recommended by the surgeon and/or desired by the member.
(4)
Prosthetic devices inserted during
surgery. Separate payment is made for prosthetic devices inserted during
the course of surgery when the prosthetic devices are not integral to the
procedure and are not included in the reimbursement for the procedure
itself.
(b) Orthotics
and prosthetics are covered for expansion adults services when:
(1) Orthotics are medically necessary when
required to correct or prevent skeletal deformities, to support or align
movable body parts, or to preserve or improve physical function.
(2) Prosthetics, including prosthetic hearing
implants and ocular prosthetics, are medically necessary as a replacement for
all or part of the function of a permanently inoperative, absent, or
malfunctioning body part. The member shall require the prosthesis for mobility,
daily care, or rehabilitation purposes.
(3) In addition, orthotics and prosthetics
must be:
(A) A reasonable and medically
necessary part of the member's treatment plan;
(B) Consistent with the member's diagnosis
and medical condition, particularly the functional limitations and symptoms
exhibited by the member; and
(C) Of
high quality, with replacement parts available and obtainable.
(c) Refer to Oklahoma
Administrative Code (OAC)
317:30-5-211.1 for definitions of
orthotics and prosthetics.
Added at 24 Ok Reg
2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 425, eff 12-1-07 (emergency);
Added at 25 Ok Reg 1161, eff 5-25-08; Amended at 27 Ok Reg 942, eff
5-13-10
