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| Section: |
Durable Medical Equipment |
| Number: |
B-54 |
| Topic: |
Orthotics |
| Effective Date: |
January 28, 2008 |
| Issued Date: |
January 28, 2008 |
| Date Last Reviewed: |
01/2008 |
General Policy Guidelines
Indications and Limitations of Coverage
An orthotic is a rigid or semi-rigid device used to support, restore, or protect body function. Orthotics may also redirect or restric motion of an impaired body part.
Orthotic devices are considered medically necessary when prescribed by a qualified provider to be used for the therapeutic support, protection, restoration, or function for an impaired body part. Orthotic devices used for other diagnoses or conditions are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.
Orthotic devices include:
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braces for leg, arm, neck, back, and shoulder;
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corsets for back or for use after special surgical procedures;
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splints for extremities;
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trusses
See Medical Policy Bulletin O-12 for additional information on Foot orthotics for conditions other than diabetes. |
Procedure Codes
Traditional Guidelines
FEP Guidelines
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. The following codes are not covered for FEP: L3040, L3050, L3060, L3215, L3216, L3217, L3219, L3221, L2120, L3222, L3332, L3480 and L3485. |
PPO Guidelines
Managed Care POS Guidelines
Publications
References
Blue Cross Blue Shield Association Medical Policy 1.03.01; Issue 1:2003 |
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Glossary
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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