BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for Absent or Nonfunctioning Body Parts (Prosthetics)

PURPOSE

To establish a basis for determining the medical necessity of replacement of absent or nonfunctioning body parts with prosthetic appliances.

DESCRIPTION

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. Prosthetic appliances may be surgically implanted or worn as an anatomic supplement.

Prosthetic appliances include, but are not limited to, the following:

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

• Cochlear implants

• Intra-ocular lenses

• Maxillofacial devices, and intra-ocular lenses as replacement of either surgically removed or congenitally absent crystalline lenses of the eye

• Penile prostheses in men suffering impotency resulting from disease or injury

• Prosthetic nose or ears

• Urethral sphincters for urinary incontinence

Non-Surgical Prostheses

• Artificial eyes

• Artificial limbs replacing all or part of absent extremities

• Colostomy and other ostomy accouterments directly related to ostomy care

• "Space shoes" when used as a substitute device in the absence of all or a substantial portion of the forefoot

• Speech aids

• Urinary collection and retention systems (Foley catheters, tubes, bags, etc.) in cases of permanent urinary incontinence

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for replacement of absent of nonfunctioning body members with prosthetic appliances.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

THERAPEUTICS:

• Artificial Intervertebral Disc

• Biventricular Pacemakers for the Treatment of Heart Failure

• Bone Lengthening for Congenital Conditions, Limb Discrepancies and Angular Deformities of Long Bones

• Breast Augmentation/Mammaplasty (Non-cancerous)

• Breast Implant Removal

• Breast Reconstructive and Symmetry Surgery Following Mastectomy

• Cochlear Implant

• Deep Brain Stimulation for the Treatment of Movement Disorders

• Electrophrenic Pacemaker

• Erectile Dysfunction - Internal Penile Prosthesis

• Hip Resurfacing

• Home Hyperalimentation (Total Parenteral/Enteral Nutrition)

• Implantable Ventricular Assist Devices (VAD) and Total Artificial Hearts (TAH)

• Keratoprosthesis

• Mentoplasty (Chin Augmentation, Genioplasty)

• Microprocessor-Controlled Prostheses for the Lower Limb

• Myoelectric Prosthetic Components for the Upper Limb

• Orthotics

• Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

• Shoulder Resurfacing

• Total Ankle Replacement

• Unicompartmental Knee Replacement

• Unicondylar Interpositional Spacer for the Treatment of Osteoarthritis

ADDITIONAL INFORMATION  

An appropriate licensed practitioner must prescribe prosthetics.

ORIGINAL EFFECTIVE DATE:  7/1979   

MOST RECENT REVIEW DATE:  8/17/2011

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.