DESCRIPTION
An orthotic (orthosis) is a rigid or semi-rigid device used to support, restore, or protect body function. Orthotics may also redirect or restrict motion of an impaired body part.
POLICY
Orthotic devices for therapeutic support, protection, restoration, or function for an impaired body part are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Orthotic devices for therapeutic support, protection, restoration, or function for an impaired body part are considered medically appropriate if an appropriate licensed practitioner prescribes the orthotics (i.e., MD, DPM [podiatrist], DC [chiropractor]).
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
Podiatric appliances (e.g., orthopedic shoes) are considered medically appropriate for the prevention of complications associated with diabetes (In accordance with the 1997 State Mandate).
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Orthotic devices may include:
Braces for leg, arm, neck, back, and shoulder
Corsets for back or for use after special surgical procedures
Splints for extremities
Trusses (including Sykes hernia device)
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Orthotics (1.03.01). Retrieved August 11, 2009 from BlueWeb. (0 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2008). Knee braces (1.03.02). Retrieved August 11, 2009 from BlueWeb. (13 articles and/or guidelines reviewed)
Collins, N., Crossley, K., Beller, E., Darnell, R., McPoil, T., & Vicenzino, B. (2008). Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: Randomised clinical trial. BMJ, 337 (a1735). (Level 2 Evidence - Industry sponsored)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Prosthetic and orthotic devices and supplies (Section 40.6, p. 4-141). The Ingenix Complete Guide to Medicare Coverage Issues.
Firestein, G. S., Budd, R. C., Harris, E. D., McInnes, I. B., Ruddy, S., & Sergent, J. S. (Eds.). (2008). Kelley’s Textbook of Rheumatology (8th ed., Chapter 64). Philadelphia: W. B. Saunders Company.
Gravlee, J. R., & Van Durme, D. J. (2007). Braces and splints for musculoskeletal conditions. American Family Physician, 75 (3), 342-348.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2605. Equipment, supplies and outpatient services for diabetic patients. Retrieved August 13, 2009 from http://www.legislature.state.tn.us/.
U. S. Food and Drug Administration. (2009, August). Center for Devices and Radiological Health. Medical Device Exemptions 510(k) and GMP Requirements: Part 890 - Physical medicine devices. Retrieved August 13, 2009 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/315.cfm?GMPPart=890#start.
ORIGINAL EFFECTIVE DATE: 7/1979
MOST RECENT REVIEW DATE: 9/10/2009
ID_BT
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.
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