+-----------------------------------+-----------------------------------+
| ## Department of Veterans Affairs | ##  VHA HANDBOOK 1173.2           |
+-----------------------------------+-----------------------------------+
| **Veterans Health                 | **Transmittal Sheet**             |
| Administration**                  |                                   |
+-----------------------------------+-----------------------------------+
| **Washington, DC 20420**          |                                   |
+-----------------------------------+-----------------------------------+

### FURNISHING PROSTHETIC APPLIANCES AND SERVICES

# 

**1. REASON FOR ISSUE:** This Veterans Health Administration (VHA)
Handbook updates the previous procedures of the Department of Veterans
Affairs (VA) for furnishing prosthetic appliances and services to
veteran beneficiaries.

**2. SUMMARY OF CHANGES:** This VHA Handbook updates current procedures.

**3. RELATED ISSUES:** VHA Directive 1173 and VHA Handbooks 1173.1
through 1173.16.

**4. RESPONSIBLE OFFICE:** The Chief Prosthetics and Clinical Logistics
Officer (10FP), is responsible for the contents of this VHA Handbook.
Questions may be referred to 202-254-0440.

**5. RESCISSIONS:** VHA Handbook 1173.2, dated November 3, 2000, is
rescinded.

**6.** **RECERTIFICATION:** This document is scheduled for
recertification on or before the last working day of

  ------------------------------------- ---------------------------------
                                        

                                        Jonathan B. Perlin, MD PhD, MSHA,
                                        FACP

                                        Under Secretary for Health
  ------------------------------------- ---------------------------------

Distribution: **RPC: 0005**

FD

Printing Date: /00

### CONTENTS

### FURNISHING APPLIANCES AND SERVICES

**PARAGRAPH PAGE**

1\. Purpose 1

2\. Furnishing Appliances 1

3\. Stock Procurement 1

4\. Repairs to Appliances 3

5\. Loan of Appliances 10

6\. VA Prosthetic and Orthotic Laboratories 12

7\. VA Restoration Clinics 15

8\. VA DDC 16

9\. Direct Purchasing by Prosthetic Activities under COCP 18

10\. Prosthetic Treatment Centers 20

11\. Major Medical and Special Equipment Committee (MMSEC) 21

12\. Visual Impairment Services Team (VIST) 23

**APPENDICES**

A. Designated Polytrauma Centers & Amputee Clinic Teams A-1

B. Designated Prosthetic Treatment Centers & iBot Evaluation Centers B-1

C. Prosthetic-Orthotic Laboratories Authorized in VA Field Facilities
C-1

### FURNISHING PROSTHETIC APPLIANCES AND SERVICES

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook establishes uniform
and consistent national policy and procedures in furnishing prosthetic
appliances to all eligible beneficiaries based upon the medical
recommendations of Prosthetic Clinic Teams, staff physicians, or
authorized fee-basis physicians. ***NOTE:** Prosthetic staff will
consider the recommendations of any private physician requesting a
prosthetic appliance to treat a service connected condition, or any
condition of a veteran 50 percent or more service connected.*

**2. FURNISHING APPLIANCES**

a\. In Department of Veterans Affairs (VA) facilities and VA nursing
home care units, all prescriptions for appliances, repairs, or
modifications requested for inpatients will be initiated sufficiently in
advance of the patient\'s anticipated release date to permit procurement
and delivery prior to discharge.

b\. Special and non-routine prosthetic appliances will require approval
of an appropriate committee, e.g., Major Medical and Special Equipment
Committee (MMSEC), Home Improvement and Structural Alterations (HISA),
VHA Headquarters, etc.

c\. The Prosthetic Representative will ensure compliance with the legal
authority to provide services as outlined in Title 38, and ensure that
the resources necessary to sustain a viable program are identified to
appropriate upper management officials.

d\. The Prosthetic Representative will review all requests from
beneficiaries or their authorized representatives for determination of
whether a previously provided appliance may be replaced or, if
circumstances indicate, referral to the appropriate clinician for a new
prescription.

e\. In the absence of a Prosthetic Representative, all requests from
patients or their authorized representatives will be referred to a
designated physician or to the Prosthetic Team.

f\. Personal equipment or appliances owned by a veteran, which have not
been furnished by VA, may be added to the veteran's VA Form 10-2319
(ADP), "Record of Prosthetic Service", at the veteran's request,
**provided that he/she meet the medical criteria for that equipment,
based on the provisions set forth in this handbook.**

**3. STOCK PROCUREMENT**

a\. If the appliance is to be procured commercially, VA Form 2237,
"Request, Turn-in and Receipt for Property or Services" will be
electronically prepared through the Veterans Health Information Systems
and Technology Architecture (VISTA) software. The printed copy of the
form will be retained, as a delivery copy, to compare with the item(s)
received. Stock items may also be procured through use of the purchase
card.

b\. Upon receipt of the appliances at the facility warehouse, delivery
will be made to the Prosthetics Service. If the received appliance meets
the specification set forth in the order, as verified by the suspense
copy, VA Form 90-2138-7 (ADP), "Order for Supplies or Service", will be
signed and dated by an authorized receiving official.

c\. **[Purchase Order Number.]{.underline}** The purchase order number
is assigned sequentially by the Integrated Funds Distribution, Control
Point Activity, Accounting and Procurement (IFCAP) process at the time
the order is obligated. In recording the transaction to the VA Form 10-
2319 (ADP), simultaneous posting to the National Prosthetic Patient
Database (NPPD) occurs. The provision of items from stock is exercised
through the Prosthetics software. Items and/or services are posted to
the VA Form 10-2319 (ADP) and deleted from the quantity of existing
stock.

d\. **[Blanket Purchase Agreements (BPA).]{.underline}** BPA's are
designed to reduce the number of daily purchases and may be established
for the purpose of obtaining large quantities of similar items and to
offer the benefit of obtaining quantity discounts. Under no
circumstances should the existence of BPA for a particular product be
used as a vehicle for denying issuance of a similar, non-BPA item that
would be more appropriate for meeting a beneficiary's medical needs.
BPAs are negotiated nationally. Items, equipment and services obtained
through BPAs are processed as described above, using VA Form 2421pc for
individual patients and VA Form 2237 for bulk stock.

e\. **[Recommended Special and/or Experimental Appliance.]{.underline}**
If a special and/or experimental appliance is recommended for issuance
to a beneficiary, VA Form 10-2641, "Authorization for Issuance of
Special and/or Experimental Appliances," will be prepared. Completion of
this form is self-explanatory; however, a thorough and comprehensive
justification for issuance of the requested item must be presented to
VHA Headquarters, in order that designated personnel can make an
appropriate decision. In addition to the diagnosis, the following
information will be required:

\(1\) A statement regarding the physical condition of the patient,
including an assessment of functional limitations and the medical
justification for the requested device.

\(2\) Reports of home visits, if applicable, including information on
accessible space, floor plan layouts, available electrical power, or
other factors effecting the use or installation of the requested
equipment.

\(3\) Alternatives that were considered, using more conventional devices
or methods.

\(4\) The ability of the patient to use and operate the device and/or
the availability of family members of family members or attendants to
assist the veteran.

\(5\) Training provided to the veteran and/or family members.

\(6\) Relevant illustrative literature or scientific articles should be
included, particularly if the item is new to the market. VA Form 10-2641
will be signed by the appropriate physician, the Prosthetics
representative, and will be forwarded to **the VPR for review and, if
necessary, forwarded to** VHA Headquarters **for approval**. A copy of
the document will be held in suspense until a decision has been
rendered. It is recommended that the \"critical comment\" on VA Form
10-2319 (ADP) be annotated to reflect the status of VA Form 10-2641. If
the request is denied, the veteran will be notified of his appeal
rights.

f\. **[Approval for Issuance of the Special and/or Experimental
Appliance.]{.underline}** If approval for issuance of the special and/or
experimental appliance is granted, the original VA Form 10- 2641 will be
returned to the field facility. Upon receipt of such approval, VA Form
10-2421 (ADP), "Prosthetic Authorization for items or Services", will be
prepared in the usual manner. In addition, a copy of the approval, VA
Form 10-2641, will be retained along with the suspense copy of the
procurement document, as authority for procurement. It will be placed in
the veteran\'s Consolidated Health Record upon receipt of the item
and/or service.

g\. **[Follow-up Procedures on All Pending Orders.]{.underline}** All
pending orders will be reviewed on a regular basis to determine that
they are being processed in a timely fashion. Use of the "IFCAP Option
List Purchase Card Transactions by Initiator" ("LPCI") will identify
obligated pending orders. Annotations to this list may include, but are
not limited to: date of follow- up, person(s) contacted, general
discussion, and changes in estimated delivery times.

**4. REPAIRS TO APPLIANCES**

a\. **[Scope]{.underline}**

\(1\) All parts procured or fabricated to replace existing parts or to
modify a previously issued appliance will be considered as \"repairs,\"
regardless of whether installation is performed by a commercial source,
a VA facility, or the beneficiary.

\(2\) Repairs will be obtained by use of either VA Form 10-2501,
Prosthetic Service Card (PSC) (**for veterans receiving prosthetic
services for a Service Connected condition),** or VA Form 10-2421**pc**,
"Prosthetic Authorization for Items or Services", or Purchase cards,
whichever is determined to be the most appropriate, under the
circumstances.

\(3\) Repairs/replacements for DME/Artificial Limbs not furnished by a
facility will be provided once a patient is enrolled at the new/referral
facility. Prosthetic staff should input the item(s) to be repaired into
the patient's 2319 as historical data for tracking purposes. If a
replacement is deemed necessary, follow standard procedures for
replacement of equipment.

\(4\) PSCs shall be provided by all prosthetic programs at field
facilities.

\(5\) Equipment repairs and services which may be authorized under the
authority of PCS include artificial limbs, aids for the blind and
veterinary services for guide dogs, orthopedic braces, and power
wheelchairs.

\(6\) PSCs are limited to the following amounts:

\(a\) Blind aids and/or braces \$150

\(b\) Power Wheelchairs \$250

\(c\) Artificial limbs \$500

\(7\) Invoices for repairs or veterinary treatment obtained under the
authority of a PSC will be submitted to and paid for by the Prosthetic
Service with Primary Service Area (PSA) responsibility where the veteran
resides.

#####  (8) When eligible beneficiaries, requiring repairs to authorized appliances, do not possess a PSC, prior approval for repairs must be given by the Prosthetic Representative, or designee, before payment of repairs can be made. *NOTE: Exceptions to this policy are found in "Procedures for Usage of PSC."*

#####  b. [Responsibility]{.underline}

\(1\) Prosthetic representatives, or designated officials, are
responsible for the overall administration of the PSCs, to include
receiving and processing all PSC invoices submitted by vendors for
repairs to appliances. Training will be provided to all subordinate
staff with reference to what types of repairs are appropriate or
acceptable cost limits that may be authorized on beneficiary appliances.

\(2\) Vendors are responsible for ensuring that the appliance being
repaired is described on the PSC and for obtaining a Form Letter (FL)
10-55, Authority to Exceed Repair Costs of Prosthetic Appliance, when
repairs exceed the authorized limitations of the card.

\(3\) Veterans are responsible for safeguarding their PSC, using it only
for the identified appliance(s) and for updating as required. Veterans
should take care to ensure that they do not sign a "blank" invoice, and
to verify that the charges on the invoice are for services received.

c\. **[Procedure]{.underline}**

\(1\) After determination of eligibility and review to assure that the
beneficiary has no previously issued card, VA Form 10-2501 will be
prepared.

\(a\) When an initial PSC is prepared, the date of preparation will be
entered in the box \"Date Card Issued\"; subsequent cards will reflect
this same initial date. \"PSC/Entitlement Records\" option in the VISTA
Prosthetic software will be exercised to collect the data necessary for
paying invoices.

\(b\) Beneficiaries with more than one type appliance, for which a PSC
is authorized, will be furnished a separate PSC for each appliance.

\(2\) **Limits for PSC Benefits**

> \(a\) [Artificial Limbs.]{.underline} The price limitation of \$500
> will be entered in the appropriate space. The level of amputation,
> specification of left or right, of serviceable artificial limbs in the
> patient\'s possession, with the year of issue, will be entered in the
> description area for each amputation.

\(b\) [Aids for the Blind.]{.underline} The price limitation of \$150
will be entered in the appropriate space. The make, model, and serial
number of each of the major aids in the patient\'s possession will be
listed. When a dog guide is used, the breed and dog\'s name; e.g.,
\"German Shepherd,\" \"Fido,\" will be entered as one item and the
harness as another.

[]{.mark}

\(c\) [Orthotic Appliances (not including foot orthotics).]{.underline}
The price limitation of \$150.00 will be entered in the appropriate
space. The "Description" area will include:

> 1\. The type of orthosis
>
> 2\. Specification of left/right extremity, specification of type of
> spinal orthosis, etc.

3\. Number of serviceable orthopedic devices in the patient\'s
possession, along with the year of issue.

\(d\) [Power Wheelchairs.]{.underline} The price limitation of \$250.00
will be entered. The make, model, and serial number of the authorized
wheelchair(s) in the patient\'s possession, with the year of issue, will
be entered in the description area.

\(3\) **Preparation and Issuance by Mail**

\(a\) When a new or replacement PSC is requested by mail, and the
personal information is not available, FL 10-216, Instructions for
Issuance of New Prosthetic Service Card, will be developed through the
VISTA Prosthetic software and mailed to the patient with a blank PSC and
a return envelope.

\(b\) Upon return of FL 10-216, the signed PSC and the old card or
statement confirming loss or destruction, the revised PSC will be
processed and sent to the patient with FL 10-215, Prosthetic Service
card instructions (Selected). The veteran\'s VA Form 10-2319 (ADP) will
be annotated to reflect the issuance of the PSC.

\(c\) When preparing FL 10-215, the appropriate box explaining the
reason for furnishing the PSC will be checked. If the PSC is replaced
because of the issuance of a different appliance, the box requesting the
destruction of the existing card will also be checked.

\(d\) When the personal information is available, the PSC will be
processed and sent to the patient with a return receipt. Screen 6 of the
VA Form 10-2319 (ADP) will be annotated to reflect the name of the
signatory on the returned receipt.

\(e\) The patient will verify the information and sign the PSC in ink in
the appropriate box. The PSC with FL 10-216 will be given to the
veteran.

\(4\) **PSC Invoices**

\(a\) Upon the receipt of VA Form 10-2520, PSC Invoice, a purchase card
obligation will be processed for the amount of the invoice using the
control point **purchase card** assigned to repairs. In the event that
it exceeds the PSC limitations, FL 10-55 will be employed.

\(b\) Every effort should be made to ensure that repairs that exceed the
limitations of the appropriate PSC are authorized before the card limit
is exceeded. There will be cases where the limit is inadvertently
exceeded before proper authorization is given; however, this is
unacceptable after more than one occurrence following documented
notification from the repair source of the proper process. In such
subsequent cases, only the card limit for the repairs will be paid, and
a copy of the invoice will be returned with the balance marked as
\"unauthorized repair.\"

\(c\) The preparation of two separate invoices to cover a repair
exceeding established PSC limits will not be approved for payment;
invoices will be prepared only for each incident of repair to
appliances.

\(5\) **Preparation and Processing of Invoices**

\(a\) After repairs have been accomplished, the vendor will prepare
invoices as illustrated on the reverse side of the PSC. VA Form 10-2520
may be used and will be furnished to vendors by the authorizing VA field
facility on request. Verification will be required, to the best of the
patient\'s ability, of the repair information and charges listed on the
invoice to ascertain that the total charges have been typed or entered
in ink or indelible pencil in the appropriate space on the invoice, and
to sign the original only of the invoice, using the same signature as
that on the PSC. Under no circumstances should the patient ever sign a
blank PSC invoice. Verifiable indications of such occurrence may result
in cancellation of the abusing beneficiary's PSC.

\(b\) The vendor will forward the original invoice and one copy, and the
original FL 10-55, if applicable, to the VA field facility indicated on
the PSC.

\(c\) On receipt of such invoices, the following actions will be taken:

[1]{.underline}. The invoice will be entered into the Prosthetic
Suspense package as a clone to the original request if less than two
years old. If greater than two years old, a new request will have to be
submitted for the repair.

[2]{.underline}. The description of the appliance repaired and the
issuance of a PSC will be checked against the information posted on the
VA Form 10- 2319 (ADP). Repair invoices for artificial limbs, aids for
the blind, and braces should be compared to delivery dates; wheelchairs
should be compared by serial numbers.

\(6\) **Other Authorized PSC Repairs**

\(a\) [Price Limitations.]{.underline} Price limitations have been
established for each appliance for which PSC repairs have been
authorized. These are clearly defined on each PSC and may not be
exceeded except in the following circumstances:

[1]{.underline}. If a PSC is presented to a VA Orthotic Laboratory, any
necessary repairs will be made without further authority, provided
facilities and necessary parts or supplies are available, and the cost
of the repairs do not exceed 50 percent of the cost of a replacement
item. If the cost exceeds 50 percent, the Prosthetic Representative with
PSA responsibility over the veteran\'s treatment will be contacted for
authorization to repair or replace the device.

[2]{.underline}. On presentation of a PSC at any VA field facility with
medical activities, the patient will be entitled to all required
prosthetic services in connection with the appliances listed on the
card, as well as to other appliances or accessories obviously required
because of the condition for which the card was issued.

[3]{.underline}. Major repairs to appliances in excess of the limitation
listed on the PSC, or emergency replacement of such an item if medically
indicated, will be provided without the necessity for prior eligibility
certification from the field facility exercising jurisdiction over the
veteran\'s case. Requests for prosthetic services under such
circumstances will be processed as follows:

[a]{.underline}. The patient will be immediately referred to an
appropriate physician, if medically necessary, for examination and
medical determination of need for the requested major repair or
replacement.

[b]{.underline}. If authorized, the Prosthetic representative, or
designee, will make all necessary arrangements, in accordance with
existing policies and procedures, to obtain immediate repairs or
replacement. ***NOTE:** Such cases will be processed as emergencies and
every effort will be made to expedite service to the patient.*

[c]{.underline}. The field facility authorizing and procuring repairs or
replacement appliances will be obligated for payment of all costs
incurred, except for costs of any repairs obtained under direct
authority of the PSC.

[d]{.underline}. When any device is in the process of being repaired by
a commercial vendor under the authority of a PSC, and it is found that
more extensive repairs are absolutely essential to restore the device to
serviceable condition, the vendor should immediately contact the
Prosthetic Representative of the field facility listed on the card. A
full explanation of the situation and the total estimated cost for the
repairs will be obtained from the vendor. A determination will then be
made as to what action is to be taken in the case. If it is agreed that
the repairs are necessary and economically feasible, FL 10-55 will be
prepared by the Prosthetic activity.

[e]{.underline}. If the quoted cost appears to be excessive for any
reason and no emergency exists, the device (preferably, along with the
patient) will be referred to the Prosthetic Service for clinical
evaluation and for possible replacement. If the need is emergent,
minimal repairs will be authorized and the patient will be scheduled for
examination.

[f]{.underline}. If all of the conditions of preceding subparagraph
4c(6)(d)[c]{.underline}. are met, but the Prosthetics Representative
cannot be contacted during non-office hours and if prosthetic repairs
must be accomplished in order to ambulate the patient, absolute minimum
essential repairs may be performed on the prerogative of both the
patient and the vendor. However, the Prosthetic representative will be
contacted by the vendor at the earliest opportunity and a complete
explanation submitted. The invoices will then be processed upon receipt.

\(b\) In using VA Form 10-2501, a terminal device may be repaired as
part of an artificial arm.

\(7\) **Revoked or Cancelled PSC.** A beneficiary's PSC will be
cancelled or revoked if:

\(a\) There is an adjudication rating action resulting in lack of
eligibility for a beneficiary for the appliance or repairs thereto.

\(b\) There is a medical determination that there is no further need for
the appliance.

\(c\) There is flagrant abuse of the benefits of the PSC, e.g., signing
blank invoices, using the card for unauthorized purchases more than
twice, etc.

[1]{.underline}. When a determination to cancel has been made, immediate
steps will be taken by the Prosthetic Representative to re-possess the
PSC. Such action will include informing the patient, in writing, of the
reasons for the action, including the statement that continued use of
the card to obtain repairs will be considered as a fraudulent act.
Revocation letters forwarded for abuse or lack of cooperation will be
sent via registered mail and will contain a statement that the patient
will obtain prior authority from the local facility of jurisdiction for
all future repair services. This letter will be developed through the
Prosthetic VISTA software \"correspondence menu\" to ensure inclusion
and ready review on VA Form 10-2319 (ADP).

[2]{.underline}. If the patient does not surrender the card, and does
not submit a letter explaining the circumstances within 45 days of
receipt of certified correspondence, VA Form 10-2319 (ADP) will be
prominently annotated through the \"critical comment\" screen #6 to
suspend payment of all subsequent invoices charged to the card. An
investigation under the auspices of the District Counsel may be required
when there is a dispute between the Prosthetic representative and the
billing vendor over legitimate billing.

\(8\) **Repairs VA Form 10-2421, Prosthetic Authorization for Items or
Services.** In the absence of a PSC or use of PSC, VA Form 10-2421**pc**
will be used to obtain repair or replacement parts for any appliances
for eligible beneficiaries \[qualifying under Pub. L. 104-262\]. Service
may be authorized up to one-half the replacement value of the item.
These forms will be processed in the usual manner.

\(9\) **Centralized Hearing Aids Repair Program**

\(a\) A national centralized program for processing hearing aids for
repair is established at the Denver Distribution Center (DDC), Denver,
CO. Except for local emergency repairs, all hearing aids in possession
of veterans will be processed for repair through this centralized
system.

\(b\) Personally purchased hearing aids may be included in the
centralized program upon approval of the Audiology and Speech Pathology
Service (ASPS) with PSA responsibility where the veteran resides and
detailed notification to the DDC. ASPS will input data through the
Remote Order Entry System.

\(c\) Upon receipt of notification indicating the issuance of a hearing
aid to a veteran not already participating in the program, the DDC will
forward a mailing carton and instructions to facilitate repairs of the
aid.

\(d\) The Prosthetic Service with PSA responsibility where the veteran
resides will authorize and pay for appropriate local emergency repairs
to hearing aids when repair by DDC is not feasible.

\(e\) VA facilities requiring repairs to hearing aids for long-term non
service- connected patients may forward such aids to the DDC. VA Form
10-2529-3, Request and Receipt for Prosthetic Appliances or Services,
should be prepared by the Prosthetic Service with PSA responsibility in
the usual manner and clearly annotated to identify the hearing aid by
manufacturer, model number and serial number.

\(f\) All costs for repairs of hearing aids by the DDC will be charged
to the Prosthetic Service with PSA responsibility where veteran resides.
Procedures for processing emergent repairs by VA field facilities will
be established at the local level.

**5. LOAN OF APPLIANCES**

a\. **[Scope]{.underline}**

\(1\) The procedures for furnishing appliances as outlined are generally
applicable to major items of medical equipment which are loaned or
furnished to eligible veterans.

\(2\) Necessary forms for managing the issuance of major items of
medical equipment and the procedures, i.e., FL 10-219, Notice to Veteran
of Loan of Medical Accessories and Receipt; FL 10-219a, Release from
Responsibility for Government Property; and FL 10-426a, Information
Letter -- Major Medical Equipment, should be created in the local
"correspondence menu" of the prosthetics VISTA software. This ensures
that a copy is reserved in VA Form 10-2319 (ADP) when the original is
sent to a beneficiary. It is not necessary that a separate letter be
sent whenever multiple or subsequent issues of the major medical
equipment are involved. One letter sent upon the issuance of the first
item is sufficient to inform the veteran of the existing policy.

\(a\) Reusable medical equipment will be recovered, if offered,
refurbished if necessary, and reissued whenever such actions are
cost-effective. For the purposes of recovery, loan items will be
depreciated at the rate of 20 percent per year from the date purchased.
If it is not cost-effective to recover a particular item, the offer will
be politely declined and the veteran or family member will be advised to
donate it to an appropriate nonprofit organization; e.g., a veterans
service organization, the Red Cross, the American Cancer Society, etc.

\(b\) Non-custom appliances and/or items will be furnished on loan when
the purchase cost of the item exceeds \$10,000 or the Durable Medical
Equipment (DME) item with a life-span of 1 to 5 years is only required
for a short period of time, generally 1 to 3 months, or less.

\(c\) Appliances and/or items whose loan periods have expired will be
deleted from the loan program and permanently issued to the veteran.

\(d\) The Prosthetic Representative must maintain a file or database of
all loaned equipment.

b\. **[Responsibility]{.underline}**

\(1\) The Prosthetic Representative is responsible for the overall
administration of the loan program. This includes identifying those
items that are to be loaned, the duration of the loan period,
establishing loan records, maintaining an inventory of returned loaned
items, and documenting the records of veterans in receipt of loaned
items.

\(2\) The Prosthetic Representative, with PSA responsibility, will
repair and/or replace any loaned equipment in the possession of a
veteran residing within that PSA.

c\. **[Procedure]{.underline}**

\(1\) The VISTA \"Loan Program\" menu will be selected. The equipment
may be placed on loan by responding to prompts for the usual
information. No item may be placed on loan that is not entered on the
veteran's VA Form 10-2319 (ADP) prior to initiating the loan process.

\(2\) VA Form 10-1439, Prosthetic Inventory Card Prosthetic - Loaner
Item, an automated loan card, will be maintained to document actions
during the serviceable life of an appliance, which will be 5 years from
the initial purchase and/or delivery date. Particular care should be
taken to ensure that the item's description, value, and purchase date is
accurately recorded, as this information is critical in the follow-up
activity.

\(3\) The VISTA software will establish the dates of follow-up. With the
exception of 'short-term" loans (1 to 12 months), the first date will be
6 months from the date of loan. Routine follow-up dates are 6 months, 12
months, and annually thereafter. When electronically transferred and
downloaded to another facility, these dates remain unchanged to
accommodate subsequent follow-up including the loan expiration date
originally established.

\(4\) Items over 5 years old will not normally be loaned, nor will items
which have been recovered after being loaned two times.

\(5\) Loaned items that are returned to inventory, that have a residual
value greater than \$6,000, will be loaned if provided to another
veteran within 5 years from the date of purchase.

\(6\) FL 10-219, incorporated in the local VISTA correspondence menu,
will be printed in duplicate and the original and one copy will be
forwarded to the patient at the time the loaned appliance is shipped or
delivered. An entry will be made in the electronic loan correspondence
suspense file pending return of the signed original from the patient.
Upon receipt of the signed copy of the FL 10-219, it will be filed in
the veteran\'s Consolidated Health Record. The electronic loan
correspondence suspense file entry will be closed.

\(7\) When alerted by the prosthetic software that a loan follow-up is
required, it will be accomplished by one of the following:

\(a\) [Personal Contact.]{.underline} If the Prosthetic representative
has personal knowledge that the veteran is using the device, the
appropriate option of the loan program will be exercised, and
\"personal\" will be selected as the type of contact.

\(b\) [Record Review.]{.underline} If the Prosthetic representative does
not have personal knowledge of the veteran\'s continued need for the
item, a review of the veteran\'s VA Form 10-2319 (ADP) or Consolidated
Health Record will be made to determine if:

> 1\. The veteran has requested service to the item 2. The veteran was
> recently issued items of a similar nature 3. The veteran's medical
> condition is such that continued need for the item can be established.

If it can be reasonably assumed that the veteran still requires the
item, the appropriate option of the loan program will be exercised, and
\"Record Review\" will be selected as the type of contact.

\(c\) [Telephone or Letter.]{.underline} If continued need cannot be
established by the preceding methods, contact will be made by telephone
or FL 10-426, "Temporary Loan Follow-up Letter". If a letter is the
method of follow-up, an entry will be made in the electronic loan
correspondence suspense file. This file may be dated for automatic
'alert' or 'print' by the inputting user. The incomplete follow-up will
appear each time the \"Follow-up Loan Report\" is viewed and remains
open, pending receipt of a response. If it can be reasonably assumed
that the veteran still requires the item, the appropriate option of the
loan program will be exercised, and \"Telephone or Letter\" will be
selected as the type of contact.

\(8\) If any methods of follow-up indicate that a veteran no longer
needs the item, appropriate arrangements for the return of the loaned
property will be made, if economically feasible. The recovery of
equipment for which recovery costs exceed the residual value of an item
will not normally be authorized, unless it is known that the item is in
very good condition and the item is suitable for reissue.

\(9\) If a follow-up letter is returned as undeliverable or no response
is received, a second attempt will be made to contact the veteran during
the next review period. If unsuccessful, the \"Comments\" section of the
inventory card will be documented with the phrase \"unable to contact,\"
the card will be printed for filing in the veteran\'s Consolidated
Health Record, and deleted from the loan program (in that order).

\(10\) When loaned items are recovered or permanently issued, a "loan
release form" will be generated from the prosthetics software
correspondence option, and forwarded to the veteran and automatically
documented on the veteran's VA Form 10-2319 (ADP).

**6. VA PROSTHETIC AND ORTHOTIC LABORATORIES**

a\. **[Scope]{.underline}**

\(1\) The size of a VA Prosthetic and Orthotics Laboratory will vary
depending on the needs of the VA medical center. Laboratories may be
established as a necessary part of patient treatment services in any VA
medical center when analyzed as cost-effective.

\(2\) The Prosthetic and Orthotic Laboratory will be assigned
organizationally to the Prosthetic Service.

\(3\) Prosthetic and orthopedic appliances, when required to be
custom-fabricated for specific veterans, may be procured from commercial
vendors where adequate facilities are conveniently available. However,
existing VA Prosthetic and Orthotic Laboratories will be used as a
primary source and will be utilized to the fullest extent possible.

\(4\) Laboratories employing two or more clinicians will serve as a
referral source for the fabrication of orthotic and/or prosthetic
devices for other VA facilities without a Prosthetic and Orthotic
Laboratory or for those facilities with smaller laboratories.

\(5\) In field facilities having established VA Prosthetic and Orthotic
Laboratories, the Chief Prosthetic and Clinical Logistics Officer
(10FP), will periodically conduct an evaluation to ensure that the:

\(a\) Laboratory is being properly utilized to its full capacity; that
the quality of appliances fabricated is completely satisfactory to
prescribing physicians and is at least equal to the best available from
local commercial vendors.

\(b\) Needs of the patients are being fully met through a combination of
internal fabrication and commercial procurement.

\(c\) Laboratory is operating as efficiently and economically as
possible.

\(d\) Current staffing is appropriate for the amount of work being done.

\(6\) In field facilities not having a VA Prosthetic and Orthotic
Laboratory, but desiring to establish one, a request for authority, with
full justification, will be submitted to the Chief Prosthetics and
Clinical Logistics Officer, through the appropriate Network Director.

\(7\) VA Prosthetic and Orthotic Laboratories have been established at
selected VA facilities (see App. C).

b\. **[Responsibility]{.underline}**

\(1\) The Chief Prosthetics and Clinical Logistics Officer, is
responsible for the formulation of policies, standards, and scope of VA
Prosthetic and Orthotic Laboratory activities, including, but not
limited to, providing training and technical assistance to the
laboratories, participating in the development and recommendation of
space, equipment, and funds to be provided, and recommending proper
staffing levels.

\(2\) The Director of a facility in which a VA Prosthetic and Orthotic
Laboratory is located will be responsible for assuring that other VA
facilities requesting services from the laboratory are afforded fair and
equitable priorities, and that the requirements of any one facility
(including the Director's own) do not take precedence over any other.
The Director will be responsible to the same degree for successful
operation of this activity as for the conduct of other activities that
solely benefit the Director\'s own facility.

\(3\) The Prosthetic and Orthotic Laboratory Supervisor will ensure that
the quality of the appliances fabricated is satisfactory to patients and
prescribing physicians, the time required for delivery is not excessive
or will not result in prolonged hospital stays for patients, and the
prices charged for such appliances are reasonable.

\(4\) The Prosthetic and Orthotic Laboratory Supervisor is responsible
to the Prosthetic Program Manager, for the efficient and economical
administration and operation of the laboratory in accordance with
established policies, standards and procedures.

##### c. [Procedure]{.underline}

\(1\) VA Prosthetic and Orthotic Laboratories design, fabricate, repair,
and fit custom-made artificial limbs, orthotic devices, corsets,
surgical belts, arch supports, and similar appliances, for VA
beneficiaries upon receipt of a properly prepared VA Form 10-2529-3,
from any facility. The fabrication of definitive artificial limbs may be
authorized in accordance with the following policy:

\(a\) Eligible veterans who are new amputees will be provided a
preparatory limb using conventional endoskeletal componentry. Once the
veteran has achieved appropriate shrinkage and is ready for a definitive
prosthesis, the socket may be replaced and the limb cosmetically
finished. These veterans will not be referred to a commercial contractor
unless such action is necessary to expedite the treatment process.

\(b\) Eligible veterans will select their provider for artificial limbs
from the listing of contract vendors, including capable VA Prosthetic
and Orthotic Laboratories. Service-connected veterans who have obtained
their most recent limb from a non-contract provider will be allowed to
have their subsequent limb manufactured by the VA non-contract provider
as long as the provider is willing to accept the geographic VA preferred
provider payment rate for the State in which the prosthetist performs
this service. The VA Prosthetic and Orthotic Laboratory will be on the
same listing, and may be selected to fabricate definitive limbs.

\(2\) Prosthetic and Orthotic Laboratories will store, modify as
necessary, fit, and issue prefabricated orthotic devices, i.e., corsets,
belts, elastic hosiery, and other appliances provided under centralized
distribution programs or purchased from commercial sources.

\(3\) Prosthetic and Orthotic Laboratories must repair artificial limbs,
orthotic devices, wheelchairs, and other appliances in possession of
eligible veterans on receipt of VA Form 10-2529-3 or on presentation by
the veteran of a valid PSC.

\(4\) Prosthetic and Orthotic Laboratories may participate in clinical
evaluation studies of newly developed prosthetic and orthotic devices
initiated by the Chief Prosthetics and Clinical Logistics Officer.

**7. VA RESTORATION CLINICS**

#####  a. [Scope]{.underline}

##### 

\(1\) Restoration Clinics will be used as a primary fabrication source
for VA beneficiaries and will be utilized to the fullest extent
possible.

\(2\) Restoration Clinics will be assigned organizationally to the
Chief, Prosthetic Service.

\(3\) In field facilities having established VA Restoration Clinics, the
facility Director will conduct an annual evaluation to ensure that the
clinic is being properly utilized to its full capacity; that the quality
of appliances fabricated is completely satisfactory and is at least
equal to the best available from local commercial facilities; that the
needs of patients are being fully met; that the clinic is operating as
efficiently and economically as possible; and that current staffing is
proper for the amount of work being done. The Chief Prosthetics and
Clinical Logistics Officer will assist in such evaluation by providing
comparative statistical analyses of all VA Restoration Clinics in
operation with specific recommendations when requested.

##### 

#####  (4) Custom made artificial eyes, facial and body restorations, cosmetic partial hands and similar appliances may be procured from commercial sources if the quality of the appliance is satisfactory, the time required for delivery is not excessive, and prices charged for such appliances are reasonable. 

#####  (5) Cosmetic gloves for partial hand amputees may be fabricated by the VA Restoration Clinics, having the capabilities to fabricate and fit these appliances, or procured from commercial sources. Such appliances will be made available to any VA facility upon receipt of a properly prepared VA Form 10-2529-3.

##### 

#####  (6) VA Restoration Clinics have been established at selected VA facilities (see App. A, VHA Handbook 1173.11).

#####  b. [Responsibility]{.underline}

\(1\) The Chief Prosthetics and Clinical Logistics Officer, is
responsible for:

\(a\) The formulation of policies, standards, and scope of VA
Restoration Clinic activities, including, but not limited to, providing
training and technical assistance to the clinics, participating in the
development and recommendation of space, equipment, and funds to be
provided, and recommending proper staffing levels.

\(b\) Directing the use of standardized materials and techniques if
required for efficient operation and/or uniformity of services to
patients.

\(2\) The facility Director in which a VA Restoration Clinic is located
is responsible for ensuring that other VA facilities requesting services
from the clinic are accorded fair and equitable priorities and that the
requirements of any one facility (including the Director\'s own) do not
take precedence over any other. ***NOTE:** The Director is responsible,
to the same degree, for successful operation of this activity, as for
the conduct of other activities that solely benefit the Director\'s own
facility.*

\(3\) The Supervisor of the Restoration Clinic must ensure that the
quality of the appliances fabricated is satisfactory to patients and
prescribing physicians, that the time required for delivery is not
excessive or will not result in prolonged hospital stay for patients,
and that the prices charged for such appliances are reasonable.

\(4\) The Supervisor of the Restoration Clinic is responsible to the
Prosthetic Representative for the efficient and economical
administration and operation of the clinic, in accordance with
established policies, standards, and procedures.

c\. **[Procedure]{.underline}**

\(1\) Restoration Clinics custom make artificial eyes, facial and body
restorations, cosmetic partial hands, ear inserts and similar appliances
for eligible VA beneficiaries on receipt of clinical notes and VA Form
10-2529-3, from all VA facilities. For referrals, VA Form 10-10EZ,
Application for Medical Benefits, is also required.

\(2\) Restoration Clinics may participate in clinical evaluation studies
of new materials and techniques initiated by the Chief Prosthetics and
Clinical Logistics Officer.

\(3\) Restoration Clinics will fabricate or repair special appliances in
possession of their own eligible VA beneficiaries, and for beneficiaries
of other field facilities, provided such work can be done with existing
staff and without detriment to direct patient services.

**8. Denver Distribution Center (DDC)**

The DDC provides for the warehousing, procurement, and distribution of
hearing aids, hearing accessories, hearing aid batteries, artificial
larnyxes, prosthetic stump socks, select aids for the blind and flexible
orthoses, and repairs hearing aids.

***NOTE:** Any changes in policy and/or procedures concerning the
centralized distribution of prosthetic items will be coordinated among
the Prosthetic and Sensory Aids Service Strategic Healthcare Group, DDC,
and the involved VHA Clinical Program.*

#####  a. [Responsibility]{.underline}

\(1\) The Office of Acquisition and Materiel Management (OA&MM) provides
internal management including:

\(a\) Supervision of the personnel involved in the centralized
distribution of prosthetic items,

\(b\) The review and development of the policies and procedures needed
to operate the centralized distribution functions,

\(c\) Preparation of annual budget estimates to support resource
requirements, and

\(d\) Initial funding from the Supply Fund (escrow account).

\(2\) VHA Headquarters Program Officials provide:

2.  

\(a\) Review of the resources requirements, and

\(b\) Oversight of the distribution functions in terms of the various
VHA programs involved, i.e., Prosthetic and Sensory Aids, Audiology and
Speech Pathology, and Blind Rehabilitation.

b\. **[Procedures]{.underline}**

\(1\) Initial items will be obtained from DDC by utilizing the Remote
Order Entry System (ROES), an automated process that orders, certifies,
issues and invoices local facilities for services rendered to
beneficiaries residing within their PSA. Similar or other select items
will be furnished to beneficiaries through VA health care facilities,
Blind Rehabilitation Centers and VA or contract Audiology Clinics.

\(2\) Replacement items may be obtained by the following processes:

\(a\) Local facility ordering for individual beneficiary through the
ROES process.

\(b\) Individual beneficiary requests by use of written correspondence
or established VA Form 2346, Veterans Request for Hearing Aid Batteries,
and VA Form 2345, Veterans Request for Stump Socks.

\(c\) Items may be furnished by direct issue to VA beneficiaries
whenever they reside or sojourn in foreign countries, provided that
written correspondence or VA Form 2345 and VA Form 2346 are mailed in an
envelope with postage of the foreign country affixed.

\(3\) Payments for the items acquired from DDC are accomplished via an
established 1358 account. Billing reports (Order Detail by
Commodity/Facility) are received from DDC at the end of each month for
payment certification.

**9. DIRECT PURCHASING BY PROSTHETIC ACTIVITIES UNDER COCP**

###### 

######  a. [Scope]{.underline}

\(1\) The Contracting Officers Certification Program (COCP) is a formal
process for the delegation of procurement authority to contracting
officers. This program establishes a chain of contracting authority
within the Department as required by law, regulations, and Executive
Order 12931, and ensures a trained, experienced and regulated workforce.

\(2\) Warrants to Prosthetic and Sensory Aids Service (PSAS) are
authorized up to \$100,000 for open market purchases and \"the maximum
order limitation of the contract,\" which means the money limit is
determined by the specific established Federal Supply Schedules,
decentralized and local beneficiary service contracts. The purchasing
authority encompasses procurement of all items required for the medical
treatment and rehabilitation of beneficiaries. Appropriate delegations
of authority are required for Prosthetic staff in addition to their
warrants to ensure compliance with MP-2, 108- 25.5002.

#####  b. [Responsibility]{.underline}

\(1\) Managers of Fiscal Service and Acquisition and Materiel Management
Service will conduct periodic reviews, to ensure that Prosthetic
purchasing activities are in compliance with applicable acquisition and
accounting regulations. Monthly reports are required to provide
information for the Federal Procurement Data System (FPDS).

\(2\) OA&MM is responsible for providing required training to the
appropriate prosthetic staff. This training should consist of \"VA Small
Purchase Procurement Procedures: Level A, Module I & II.\"

\(3\) All PSAS personnel involved in purchasing must complete the
required training, pass the written exam, and obtain a warrant. A
pre-test will be administered by the responsible training official to
determine the level of familiarity or training required. A post-test
will be administered to ensure successful completion of the training and
to issue a warrant. Any PSAS employee requiring a warrant, who has not
been provided the requisite training for reasons beyond the employee's
control, may be issued an interim warrant for a period of 90 days from
the date of issuance.

c\. **[Procedures]{.underline}**

**(1)** **Purchase Card Procurement.** The Purchase Card, a procurement
card with a pre-set monetary limit, will be the primary method of
authorizing purchases by designated employees. The use of this card
results in obligations against a specific fund control point in a
sequential manner. Available fund control balances will not reflect
purchase charges until reconciliation of applicable invoices.

\(a\) PC 2421 is the software option for generating a Purchase Card
document containing the necessary information to procure the items
and/or services requested.

\(b\) Whenever feasible, deliveries of Purchase Card items should be
made directly to the cardholder. However delivery of equipment and/or
supplies may be to the veteran, the Prosthetic Department, or to the
facility's receiving warehouse.

\(c\) A Dispute Officer or Purchase Card Auditor is responsible for
coordinating and monitoring billing errors, disputed procurements, and
credits which can not be resolved within 30 days. Activity of this type
is identified as a Statement of Questioned Item (SQI).

**(2)** VA Form 1358, Estimated Miscellaneous Obligation or Change in
Obligation, may be established on a monthly basis for utilizing known
sources of procurement not capable of processing orders through the
Purchase Card system. VA Form 1358 will be closed on a monthly basis in
compliance with established fiscal regulations.

\(a\) A review of the past 12 months of activity with the source(s)
requiring VA Form 1358 usage will be conducted to determine the average
monthly allocation.

\(b\) Funds used in establishing VA Form 1358s are deducted from
assigned control points on the basis of appropriate BOC designation. The
authorization number, for example C80423, provided by Fiscal Service
delineates the year (C8), month (04), and expenditure purpose (23) in an
alphanumeric format.

\(c\) When control point balances are not sufficient to support the VA
Form 1358 requirement, a written request to Fiscal Service justifying
the need for additional funds will be made.

\(d\) The IFCAP option of VISTA will be used to create and record
sequential transactions against the balance of the existing VA Form
1358. These transactions are identified as purchase order numbers, i.e.,
#POC40823-0002, when using documents other than those in the Purchase
Card system.

\(3\) **VA Form 10-2421.** VA Form 10-2421 will be used when the
Purchase Card is not accepted by the procurement source. It must be
obligated against an established VA Form 1358. Use of this form will
require that the vendor submit an invoice which must be certified for
payment purposes.

\(4\) **Rescinding of Procurement Authority by PSAS Under COCP**

\(a\) Authority to procure under COCP may be rescinded when supplies and
services are not consistent with organizational responsibilities and are
outside the applicable VA Acquisition Regulations (VAAR) and Federal
Acquisition Regulations (FAR).

\(b\) Any decision by the local contracting officer to rescind a warrant
for other than normal reasons, i.e., change of duty station, retirement,
etc., will be reported to the Deputy Assistant Secretary for Acquisition
and Materiel Management and the Chief Prosthetics and Clinical Logistics
Officer through the Veterans Integrated Services Network (VISN)
Director, along with a complete explanation of the circumstances leading
to the rescission action. The decision shall be reviewed by both OA&MM
and VHA Program staff. The local contracting officer will be notified in
writing as to the concurrence or non- concurrence in the warrant
rescission.

**10. PROSTHETIC TREATMENT CENTERS**

a\. **[Scope.]{.underline}** The facilities designated as Prosthetic
Treatment Centers (PTCs) in Appendix B have established amputee clinic
teams, experienced Prosthetic Staff and Physical Medicine and
Rehabilitation Service personnel capable of providing assistance
necessary to resolve difficult prosthetic problems. They may also have a
substantial number of special medical programs, e.g., Spinal Cord Injury
Service (SCIS), Spinal Cord Injury Outpatient Support Clinic (SCI/OSC),
Visual Impairment Services Team (VIST), Hospital-based Primary Care
(HBPC), Prosthetic-Orthotic Laboratory (POL), Restoration Clinic (RC),
Blind Rehabilitation Clinic (BRC), Driver rehabilitation (DR), Geriatric
Research, Education, and Clinical Care (GRECC), etc., and the personnel
experienced in treating specific disabilities which require prosthetic
appliances and/or equipment.

#######  b. [Responsibility]{.underline} {#b.-responsibility-3 .unnumbered}

\(1\) The PTC will ensure that appropriate prescriptions are developed
and that protocol checkout procedures are followed on all appliances
required for all authorized patients referred by other VA field
facilities.

\(2\) The PTC provides or arranges for adequate pre-prosthetic therapy
and post- prosthetic training in the use of prosthetic devices.

\(3\) A paramount responsibility is to fabricate/fit artificial limbs,
orthotic appliances, orthopedic shoes, artificial eyes, cosmetic
restorations, and similar devices. When required devices are
commercially procured, the PTC will monitor the adherence to
prescription on the same basis as in-house fabrication.

\(4\) The PTC initiates and, after approval by VHA Headquarters,
conducts limited research studies in the field of prosthetics or
orthotics dealing with the development of new materials, devices, or
fabrication techniques for applicants or with the problems and reactions
of patients wearing or using devices.

\(5\) The PTC provides the professional and technical guidance in the
training of all employees who have an interest in prosthetics.

\(6\) The Prosthetic Representative will be responsible for coordinating
all aspects of required care, and arranging for necessary patient
travel.

\(7\) The clinical staff normally involved in the treatment of the
patient\'s disability, e.g., spinal cord injury, blindness, amputation,
etc., will be responsible for the care of the patients referred to a
facility designated as a PTC.

c\. **[Procedures]{.underline}**

\(1\) Patients to be considered for referral to a facility designated as
a PTC include those with conditions deemed to be complicated or unusual
enough to require specialized evaluations, prescription, fabrication and
training to resolve the patient\'s problem.

\(2\) Referrals will be arranged by the following process:

\(a\) Communication between the referral and receiving facility
regarding the need for clinical records, pertinent findings with regard
to other known medical conditions is a prerequisite.

\(b\) The appropriate administrative records such as VA Form 10-10EZ, VA
Form 10-2529-3, and supportive medical documentation will be provided to
the PTC when a patient referral is accepted.

\(c\) If a facility referral results in a prescription for an appliance,
the prescribing facility's Prosthetic Treatment Center or Prosthetic
Service will normally provide the equipment unless arrangements between
the affected VPRs have been made. The most efficient, cost-effective
method of procurement will be employed to ensure the continuum of care
for the patient is not compromised (i.e., a hospital bed that may be
available for delivery from referral site's contract vendor may be the
best source in filling an order than having the prescribing facility
order and/or ship across VISN lines).

\(d\) If a facility referral results in a surgical procedure involving
any type of Prosthetic implant, the facility performing the surgery is
responsible for the cost of the implant(s).

\(e\) The PTC must provide copies of documented treatment to the
referring Prosthetic Representative within 15 working days of any
episode of care.

**11. MAJOR MEDICAL AND SPECIAL EQUIPMENT COMMITTEE (MMSEC)**

#### 

####  a. [Scope]{.underline}

\(1\) All facilities providing prosthetic equipment and/or appliances
should establish a MMSEC. The MMSEC should be comprised of knowledgeable
medical, therapy, engineering, and administrative specialists with PSA
responsibility for prosthetic services; referrals will be made when the
expertise does not exist at the local VA medical center.

\(2\) The MMSEC may review requests for major items; e.g., environmental
control systems, motorized wheelchairs, hospital beds, patient lifts,
respiratory equipment, etc., as well as special items of automobile
adaptive equipment; i.e., van modifications, sensitized brakes and
steering systems. Special equipment may also include experimental
appliances and/or devices as well as unusual requests for modalities of
care.

\(3\) The MMSEC will be outlined in a medical center Policy Memorandum,
meet on a regularly scheduled basis, and maintain minutes.

b\. **[Responsibility]{.underline}**

\(1\) The MMSEC Chairperson, a physician who is knowledgeable about
prosthetic equipment and rehabilitation, will be charged with the direct
professional responsibility for all patients referred to the Committee.

\(2\) The Prosthetic Representative will serve as the coordinator and be
responsible for the overall administrative management of the Committee.
The remaining composition of the MMSEC will be flexible and should
include a specialty physician involved in the patient\'s treatment, a
rehabilitation medicine therapist, a nurse, a driver rehabilitation
specialist, a social worker, and a biomedical engineer (when indicated).

\(3\) The MMSEC will review prescriptions written by fee-basis or
private physicians to ensure that the requested items are necessary for
the treatment or rehabilitation of the veteran.

\(4\) The MMSEC will arrange for home visits necessary to assess the
available space in the veteran\'s home, power capability, ingress or
egress to the home and/or bathroom facilities, and the need for the
requested equipment.

\(5\) The MMSEC will finalize prescriptions for the needed equipment and
arrange for training of the veteran and/or care provider in the use and
operation of the equipment.

#####  c. [Procedure]{.underline}

\(1\) Upon receipt of a request that requires MMSEC consideration, the
beneficiary will be afforded ample opportunity to attend the meeting for
presenting information that may not be a part of the medical record. The
veteran\'s personal comments and desires will be solicited before a
final decision is made; this participation will be encouraged.

\(2\) Scheduling of veterans to the Committee will be accomplished
through the VISTA appointment menu. Relevant medical records will be
obtained for the meeting.

\(3\) The Committee coordinator will briefly outline the cases to be
considered prior to seeing the veteran; the driver training specialist
and/or therapist (as applicable) will give a brief verbal summary of
each case.

\(4\) The medical findings and recommendations will be included in the
veteran\'s medical records. Appropriate prescriptions will be written to
cover all approved items. The MMSEC chairperson will arrange for:

\(a\) Any medical consultation, if indicated.

\(b\) Professional training, if indicated.

\(5\) The MMSEC Committee coordinator will prepare correspondence to the
beneficiary and/or representatives on its decisions; decisions will be
communicated to the veteran including the reasons for denial and the
veteran will be advised in writing regarding appellate and
reconsideration rights.

\(6\) The MMSEC Committee coordinator will arrange for the provision of
the approved items and/or services, and prepare a VA Form 10-2641, for
submission to the VISN and VHA Headquarters, if required.

**12. VISUAL IMPAIRMENT SERVICES TEAM (VIST)**

a\. **[Scope]{.underline}**

\(1\) This team will serve as the primary source for determining the
specialized and/or custom equipment needs of all visually impaired and
blind veterans eligible for VA health care, and will make necessary
referrals to BRCs.

\(2\) The team will be comprised of health care and allied health care
professionals charged with the responsibility for determining the
comprehensive services required by a visually impaired veteran.
Representatives may include, but are not limited to, the following
Services: Ophthalmology, Optometry, Medicine, Audiology and Speech
Pathology, Prosthetics, Social Work, Nursing, Administration, Vocational
Rehabilitation, Adjudication and Veterans Benefits Administration. The
VIST may also include a representative from the local Blinded Veterans
Association as well as a representative from a local agency for the
blind.

\(3\) The VIST chairperson will be elected by the team members and will
serve a 1- year term.

\(4\) Veterans enrolled in the VIST Program will be offered an annual
evaluation for continued appropriateness of equipment, medical and
social needs.

c\. **[Responsibility]{.underline}**

\(1\) The Prosthetic Representative will provide prescribed equipment
and repairs for all eligible blind and visually impaired veterans.

\(a\) The Prosthetic Representative at a field facility with a BRC will
provide the initial low-vision aid or blind equipment recommended for
all veterans who successfully complete training at that facility and
ensure that a copy of the 2319 is forwarded to the patient's prosthetic
service if patient is out of the PSA.

\(b\) The Prosthetic Representative at the facility with PSA
responsibility for the veteran will provide replacement and repairs to
low vision aids or blind equipment provided by the BRC.

\(2\) The VIST Coordinator will carry overall responsibility to
coordinate, act as consultant and as resource person, blindness services
for blinded veterans. ***NOTE:** Recommendations for blind aids from
other disciplines, not developed through the VIST, will be referred to
the VIST Coordinator.* The VIST Coordinator will work with Prosthetics
to obtain the appropriate blind aids.

c\. **[Procedure]{.underline}**

\(1\) All team members will determine and ensure that legally blind
veterans with whom they have contact are enrolled in the VIST Program.

\(2\) The treatment records of all VIST enrollees will be reviewed to
ensure that they are evaluated at least annually by designated
disciplines of the team.

\(3\) The Blind Rehabilitation Outpatient Specialist (BROS) is
responsible for recommending prosthetic equipment for veterans
participating in the BROS Program.

\(4\) The VIST Coordinator is responsible for assisting eligible
veterans in applying for blind rehabilitation training.

\(5\) Prosthetic requests will be developed by VIST for all items and/or
services deemed necessary for any treatment of VIST enrollees. VA Form
10-2641 will be required when requests are for special mechanical or
electronic devices, i.e., speech recognition systems, computers, and
software.

### Designated Polytrauma Centers

**VISN6 VISN 8**

Richmond, VA Tampa, FL

**VISN 12 VISN 21**

Minneapolis, MN Palo Alto, CA

**Amputee Clinic Teams**

### 

### VISN 1 VISN 2

Boston Health Care System Albany, NY

Manchester, NH Syracuse, NY

Providence, RI Bath, NY

Togus, ME Canandaigua, NY

Connecticut Health Care System

White River Junction, VT **VISN 4**

Altoona, PA

### VISN 3 Butler, PA

Bronx, NY Coatesville, PA

Brooklyn, NY Erie, PA

New Jersey Health Care System Lebanon, PA

New York, NY Philadelphia, PA

Northport, NY Pittsburgh, PA

Hudson Valley Health Care System Wilkes-Barre, PA

Wilmington, DE

### VISN 6 

Asheville, NC **VISN 5**

Hampton, VA Maryland Health Care

Durham, NC System

Fayetteville, NC Martinsburg, WV

## Richmond, VA Washington, DC 

Salem, VA

Salisbury, NC

Beckley, WV **VISN 8**

Ft. Myers, FL OPC

**VISN 7** Bay Pines, FL

Atlanta, GA Miami, FL

Augusta, GA North Florida/South Georgia

Birmingham, AL Health Care System

### Charleston, SC San Juan, PR

Columbia, SC Tampa, FL

Dublin, GA Brevard, FL OPC

Montgomery, AL Orlando, FL

### Amputee Clinic Teams (cont'd)

### 

### VISN 9 VISN 10

Lexington, KY Chillicothe, OH

Memphis, TN Cleveland, OH

Mountain Home, TN Columbus, OH

Nashville, TN Dayton, OH

Murfreesboro, TN

Louisville, KY **VISN 12**

Huntington, WV Chicago (Lakeside), IL

Chicago (Westside), IL

### VISN 11 Hines, IL

Ann Arbor, MI Milwaukee, WI

Detroit, MI North Chicago, IL

Indianapolis, IN Madison, WI

Battle Creek, MI Tomah, WI

Danville, IL

Marion, IL **VISN 16**

Ft. Wayne, IN Alexandria, LA

Biloxi, MS

**VISN 15** Houston, TX

Columbia, MO Jackson, MS

Kansas City, MO Little Rock, AR

Leavenworth, KS Muskogee, OK

St. Louis, MO New Orleans, LA

Topeka, KS Oklahoma City, OK

Wichita, KS Shreveport, LA

Marion, IL Tulsa, OK OPC

### VISN 17 VISN 18

Dallas, TX Albuquerque, NM

San Antonio, TX Amarillo, TX

Temple, TX El Paso, TX OPC

Phoenix, AZ

### VISN 19 Tucson, AZ

Denver, CO

Salt Lake City, UT **VISN 20**

Cheyenne, WY Boise, ID

Portland, OR

Roseburg, OR

###  Puget Sound 

###  Healthcare System

### Amputee Clinic Teams (Cont'd)

### 

### VISN 21 VISN 22

Fresno, CA Las Vegas, NV

Honolulu, HI Loma Linda, CA

Palo Alto, CA Long Beach, CA

Reno, NV Los Angeles, CA OPC

San Francisco, CA San Diego, CA

Northern California HealthCare System Sepulveda, CA

West Los Angeles, CA

**VISN 23**

Fargo, ND

Minneapolis, MN

Sioux Falls, SD

Des Moines, IA

Iowa City, IA

Knoxville, IA

Lincoln, NE

Omaha, NE

**Designated Prosthetic Treatment Centers**

### VISN 1 VISN 2

Boston Health Care System Albany, NY

West Haven, CT Buffalo, NY

Syracuse, NY

### VISN 3 

Bronx, NY **VISN 4**

Brooklyn, NY Pittsburgh, PA

East Orange, NJ Wilkes-Barre, PA

New York, NY

**VISN 6**

**VISN 5** Richmond, VA

Washington, DC Hampton, VA

Maryland Health Care System Durham, NC

### 

### VISN 7 VISN 8

Augusta, GA Bay Pines, FL

Birmingham, AL Miami, FL

Columbia, SC San Juan, PR

Decatur (Atlanta), GA Tampa, FL

###  West Palm Beach, FL

**VISN 9** North Florida/South Georgia

Memphis, TN

Nashville, TN **VISN 10**

Louisville, KY Cleveland, OH

Cincinnati, OH

### VISN 11

Detroit, MI **VISN 12**

Indianapolis, IN Hines, IL

###  Chicago (WS), IL

### VISN 15 Milwaukee, WI

Kansas City, MO

St. Louis, MO **VISN 17**

Dallas, TX

### VISN 16 San Antonio, TX

Houston, TX Temple, TX

Little Rock, AR

New Orleans, LA **VISN 19**

Oklahoma City, OK Denver, CO

Jackson, MS Salt Lake City, UT

###  

### VISN 18 VISN 20

New Mexico Health Care System Portland, OR

Phoenix, AZ Puget Sound

Southern Arizona Health Care System Healthcare System

### Designated Prosthetic Treatment Centers (Cont'd)

### VISN 21

Palo Alto, CA **VISN 22**

San Francisco, CA Sepulveda, CA

Long Beach, CA

### VISN 23 San Diego, CA

Minneapolis, MN West Los Angeles, CA

**Designated iBOT Evaluation Centers**

**VISN 1 VISN 22**

West Roxbury, MA San Diego, CA

**VISN 2 VISN 23**

Buffalo, NY St. Louis, MO

Albany, NY

**VISN 3**

Bronx, NY

**VISN 5**

Washington, DC

**VISN 8**

Gainesville, FL

**VISN 9**

Nashville, TN

**VISN 12**

Milwaukee, WI

**VISN 17**

Dallas, TX

**VISN 19**

Denver, CO

**VISN 20**

Seattle, WA

## Prosthetic/Orthotic Laboratories 

**Authorized in VA Field Facilities**

**[Facility Station \# Prosthetic/Orthotic]{.underline}**

**VISN 1**

Boston, MA 523 P/O

West Roxbury, MA 523A4 P/O

**VISN 2**

Albany, NY 528A8 P/O

Buffalo, NY 528 P/O

Syracuse, NY 528A7 P/O

**VISN 3**

New York, NY 630 P/O

**VISN 5**

Martinsburg, WV 613 P/O

Baltimore, MD 512 P/O

**VISN 6**

Hampton, VA 590 P/O

Richmond, VA 652 P/O

**VISN 7**

Atlanta, GA 508 P/O

Montgomery, AL 619 P/O

**VISN 8**

Tampa, FL 673 P/O

West Palm Beach, FL 548 P/O

Miami, FL 546 P/O

Bay Pines, FL 516 P/O

Gainesville, FL 573 P/O

**VISN 9**

Lexington, KY 596 P/O

**VISN 10**

Cincinnati, OH 539 P/O

**VISN 11**

Detroit, MI 553 P/O

Ann Arbor, MI 506 P/O

**[Facility Station \# Prosthetic/Orthotic]{.underline}**

Indianapolis, IN 583 P/O

Danville, IL 550 P/O

**VISN 12**

Hines, IL 578 P/O

**VISN 15**

Wichita, KS 589A7 O

**VISN 16**

Houston, TX 580 P/O

Oklahoma City, OK 635 P/O

Little Rock, AR 598 P/O

Alexandria, LA 502 P/O

Jackson, MS 586 P/O

**VISN 17**

Dallas, TX 549 P/O

San Antonio, TX 671 P/O

**VISN 18**

Phoenix, AZ 644 P/O

Tucson, AZ 678 P/O

**VISN 20**

Seattle, WA 663 P/O

Portland, OR 648 P/O

**VISN 21**

Martinez/Sacramento, CA 612 P/O

San Francisco, CA 662 P/O

Palo Alto, CA 640 P/O

**VISN 22**

Long Beach, CA 600 P/O

West Los Angeles 691 P/O

Loma Linda, CA 605 P/O

San Diego, CA 664 P/O

**VISN 23**

Minneapolis, MN 618 P/O