California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 2 - Definitions › Section 51161 - Orthotic and Prosthetic Appliances and Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions shall apply only to Sections
						51315,
						51315.1 and
						51315.2:
(a) "Abduction and Rotation Bar" means a
					 rigid bar that is attached to the feet to maintain appropriate positioning of
					 one or both feet.
(b) "Abduction
					 Position, Custom Fitted Orthosis" means a custom-fitted
					 shoulder-elbow-wrist-hand orthosis designed specifically to control abduction
					 of these areas.
(c) "Above Elbow"
					 means trans-humeral as it relates to prostheses or levels of amputation across
					 the long axis of the humerus.
(d)
					 "Above Knee" means trans-femoral as it relates to prostheses or levels of
					 amputation across the long axis of the femur.
(e) "Activities of Daily Living" or "ADLs"
					 means those activities performed by an individual for essential living
					 purposes, such as bathing, eating, toileting, ambulation, dressing and
					 transferring.
(f) "Addition" means
					 any provision that is different from or not included in the base appliance that
					 enhances or facilitates the intended function of the base appliance.
(g) "Ancillary Orthotic Device" means an
					 orthosis that is not otherwise included under any other orthotic
					 grouping.
(h) "Ankle-Foot Orthosis"
					 means an orthosis that traverses the ankle and foot.
(i) "Anterior-Posterior-Lateral Control
					 Orthosis" means an orthosis that traverses the cervical, thoracic, lumbar or
					 sacral areas to provide control of anterior, posterior and lateral motion to
					 these areas of the spine.
(j)
					 "Appliance" means an orthosis or prosthesis that is applied to the appropriate
					 body part to modify or replace the structural and functional characteristic of
					 the neuromuscular and skeletal systems.
(k) "Attachment" means any provision that is
					 different from or not included in the base appliance that changes the base
					 appliance's function beyond its originally intended function.
(l) "Backup Appliance" means another of the
					 same prosthetic or orthotic appliance for the purpose of being used in the
					 event the patient's primary appliance is unable to be used.
(m) "Base Appliance" means an appliance that
					 provides the essential or fundamental function designed for the
					 appliance.
(n) "Below Elbow" means
					 trans-radial as it relates to prostheses or levels of amputation across the
					 long axis of the radius or ulna.
(o) "Below Knee" means trans-tibial as it
					 relates to prostheses or levels of amputation across the long axis of the tibia
					 or fibula.
(p) "Bilateral" means
					 being of, or pertaining to both sides of the body.
(q) "Body Jacket" means a rigid or semi-rigid
					 orthosis that encompasses the torso to limit spinal motion.
(r) "Cervical and Multiple Post Collar
					 Orthosis" means a collar that fits around the neck to provide support and
					 protection to the cervical spine.
(s) "Cervical Orthosis" means an orthosis
					 that traverses the cervical vertebrae.
(t) "Cervical-Thoracic-Lumbar-Sacral
					 Orthosis" means an orthotic grouping that includes sacroiliac orthoses, lumbar
					 orthoses, lumbar-sacral orthoses, and anterior-posterior-lateral control
					 orthoses; each individual orthosis traverses the cervical, thoracic, lumbar or
					 sacral vertebrae.
(u)
					 "Cervical-Thoracic Orthosis" means an orthosis that traverses the cervical and
					 thoracic vertebrae.
(v)
					 "Compression Burn Garment" means a stocking worn over a burned area(s) of the
					 body that provides pressure as an aid to healing and reduction of scar
					 tissue.
(w) "Computer Aided
					 Design/Computer Aided Manufacture Model" or "CAD/CAM Model" means an appliance
					 fabricated with the aid of a three-dimensional positive or negative image or
					 digital scanning of the patient's limb(s).
(x) "Conventional Shoes" means non-orthopedic
					 shoes.
(y) "Cranial Orthosis" means
					 a helmet that fits over the head of the patient for the primary purpose of
					 molding the skull, and may provide some protection.
(z) "Custom Fabricated Appliance" or "Custom
					 Fabrication" means an appliance constructed for a specific patient by obtaining
					 individual measurements, fashioning a pattern or creating a mold, using either
					 a plaster cast, or with a positive or negative impression or using a scanning
					 device.
(aa) "Custom Fitted
					 Appliance" means a prefabricated appliance that requires individual adjustment,
					 alteration or assembly for safe and optimal application to a specific
					 patient.
(bb) "Custom Made" means
					 the same as custom fabricated.
(cc)
					 "Date of Service" means the date the appliance was received by the
					 patient.
(dd) "Definitive
					 Prosthetic Appliance" or "Definitive Prosthesis" means a prosthesis intended
					 for long-term use containing components suitable for the full range of
					 functional activities the amputee may be able to perform.
(ee) "Device" means the same as
					 appliance.
(ff) "Direct Formed
					 Appliance" means an appliance in which material is molded over the involved
					 portion of the patient's body and ultimately becomes the appliance or an
					 essential part of the appliance for that patient.
(gg) "Dynamic Flexor Hinge, Reciprocal Wrist
					 Extension/Flexion, Finger Flexion/Extension Orthosis" means a custom-made
					 orthosis that traverses the wrist, hand and fingers to control extension and
					 flexion of these areas.
(hh) "Elbow
					 Orthosis" means an orthosis that traverses the elbow.
(ii) "Endoskeletal Prosthesis" means a
					 prosthesis that is composed of an internal pylon system that provides
					 structural integrity to the appliance and provides the prosthesis' main support
					 by accepting the stress of the body's weight or functional
					 activities.
(jj) "Exoskeletal
					 Prosthesis" means a prosthesis that is composed of a rigid external shell that
					 provides structural integrity to the appliance and provides the prosthesis'
					 main support by accepting the stress of the body's weight or functional
					 activity.
(kk) "External Power"
					 means an orthosis or prosthesis that relies on a force other than that from the
					 user's body to operate, such as from a battery powered motor.
(ll) "Finger Orthosis" means an orthosis that
					 traverses the finger.
(mm) "Foot
					 Orthosis" means an orthosis that traverses the foot.
(nn) "Foot Prosthesis" means a prosthesis
					 that replaces all or part of an amputated or deformed foot.
(oo) "Fracture Orthosis" means an orthosis
					 that traverses the upper or lower extremity to stabilize and support an
					 extremity fracture.
(pp) "Gradient
					 Compression Stocking" means a garment with variable degrees of pressure,
					 typically from highest pressure in the distal parts of the garment with a lower
					 pressure in the proximal parts of the garment.
(qq) "Grouping," when used with "orthotic" or
					 "prosthetic" means more than one appliance or service that has been placed
					 together in the same procedural code classification.
(rr) "Hallux-Valgus Splint" means a device
					 that fits over the big toe to maintain proper anatomical position of the
					 toe.
(ss) "Halo Procedure" means a
					 metal structure connected to a skull ring with pins inserted into the skull and
					 attached to a body jacket or other orthosis to hold the metal structure in
					 place in order to immobilize the cervical spine.
(tt) "Hand-Finger Orthosis" means an orthosis
					 that traverses the hand and finger areas.
(uu) "Hand Orthosis" means an orthosis that
					 encompasses the whole or any part of the hand.
(vv) "Hemipelvectomy Prosthesis" means a
					 prosthesis for an amputation that is performed through a portion of the
					 pelvis.
(ww) "Hip Disarticulation
					 Prosthesis" means a prosthesis for an amputation through the hip
					 joint.
(xx) "Hip-Knee-Ankle-Foot
					 Orthosis" means an orthosis that traverses the hip, knee, ankle and foot
					 areas.
(yy) "Hip Orthosis" means an
					 orthosis that traverses the hip area.
(zz) "Immediate and Early Post Surgical
					 Procedure" means amputation and prosthetic appliance management that begins
					 immediately or very soon following surgical closure of the original amputation
					 wound or a residual limb revision wound.
(aaa) "Infant Immobilizer" means a device
					 that restricts movement of the infant in order to stabilize the infant's
					 cervical and upper thoracic spine and airway.
(bbb) "Initial Prosthesis" means a direct
					 formed temporary appliance provided as part of the immediate and early post
					 surgical and prosthetic appliance management.
(ccc) "Insert" means the same as foot
					 orthosis.
(ddd) "Instrumental
					 Activities of Daily Living" or "IADLs" means those activities that support
					 activities of daily living and the capacity for normal activity, including
					 employment, such as outside mobility, shopping, transportation, housework,
					 hygiene, laundry, meal preparation and medication management.
(eee) "Knee-Ankle-Foot Orthosis" means an
					 orthosis that traverses the knee, ankle and foot areas.
(fff) "Knee Disarticulation Prosthesis" means
					 a prosthesis for an amputation through the knee joint.
(ggg) "Knee Orthosis" means an orthosis that
					 traverses the knee area.
(hhh)
					 "Legg-Perthes Orthosis" means a hip orthosis that is designed especially for
					 the patient with Legg-Perthes deformity.
(iii) "Lumbar Orthosis" means an orthosis
					 that traverses the lumbar area.
(jjj) "Lumbar-Sacral Orthosis" means an
					 orthosis that traverses the lumbar and sacral areas.
(kkk) "Mobile Arm Support" means an abduction
					 position, custom fitted orthosis that is designed specifically for a patient
					 who requires support attached to a wheelchair, chair or table.
(lll) "Molded to the Patient" means a custom
					 fabricated appliance.
(mmm)
					 "Off-the-Shelf Appliance" means an orthotic or prosthetic appliance that fits a
					 patient without assembly or structural modification.
(nnn) "Orthopedic Footwear" means an orthotic
					 grouping that includes stock orthopedic shoes, stock conventional shoes and
					 custom-made orthopedic shoes.
(ooo)
					 "Orthopedic Shoes" means an orthotic grouping that includes Hallux-Valgus
					 splint, abduction and rotation bars, orthopedic footwear and shoe modifications
					 of stock orthopedic shoes and stock conventional shoes; or shoes that have
					 features that are designed for a medical condition(s) of the foot or ankle,
					 such as extra room or depth, support, or ability to be modified.
(ppp) "Orthosis" means an externally applied
					 appliance used to modify the structural and functional characteristics of the
					 neuromuscular and skeletal systems.
(qqq) "Orthotic Devices -- Lower Limb
					 (Extremity)" means an orthotic grouping that includes hip orthoses, Legg
					 Perthes orthoses, knee orthoses, ankle-foot orthoses, knee-ankle-foot orthoses
					 -- or any combination, torsion control: hip-knee-ankle-foot orthoses, torsion
					 control: hip-knee-ankle-foot orthoses (tibial fracture casts), torsion control:
					 hip-knee-ankle-foot orthoses (femoral fracture casts), reciprocating gait
					 orthoses, and orthotic devices -- lower limb (extremity) (additions to lower
					 extremity orthoses).
(rrr)
					 "Orthotic Devices -- Lower Limb (Extremity) (Additions to Lower Extremity
					 Orthoses)" means an orthotic grouping that includes additions to fracture
					 orthoses, additions to lower extremity orthoses: shoe-ankle-shin-knee,
					 additions to straight knee or offset knee joints (knee joints), additions:
					 thigh-weight bearing -- gluteal/ischial weight bearing, additions: pelvic and
					 thoracic control, additions: general, and custom foot orthoses.
(sss) "Orthotic Devices -- Scoliosis
					 Procedures" means an orthotic grouping that includes
					 cervical-thoracic-lumbar-sacral orthoses, thoracic-lumbar-sacral orthoses (low
					 profile) and other scoliosis procedures (body jackets).
(ttt) "Orthotic Devices -- Upper Limb" means
					 an orthotic grouping that includes shoulder orthoses; elbow orthoses;
					 wrist-hand-finger orthoses; additions to upper limb orthoses; dynamic flexor
					 hinge, reciprocal wrist extension/flexion, finger flexion/extension orthoses;
					 external power orthoses and other wrist-hand-finger orthoses -- custom
					 fitted.
(uuu) "Prefabricated
					 Appliance" means an appliance that has been manufactured from standard molds or
					 patterns with no specific patient in mind.
(vvv) "Preparatory Prosthesis" means a
					 temporary prosthetic appliance utilized to prepare the residual limb for
					 eventual fitting and to evaluate the appropriateness of selected technology and
					 the patient's ability to use a definitive prosthesis.
(www) "Primary Appliance" means the principal
					 appliance intended to be used by the patient.
(xxx) "Procedure" or "Special Procedure"
					 means an appliance, addition, attachment, adaptation or feature that is
					 designed to meet a specific medical need.
(yyy) "Prosthesis" means an externally
					 applied appliance used to replace wholly, or in part, an absent or deficient
					 body part.
(zzz) "Reciprocating
					 Gait Orthosis" means a bilateral hip-knee-ankle-foot orthosis that transfers
					 motion energy from one leg to the other, aiding or enabling
					 ambulation.
(aaaa) "Replacement
					 Glove" means a passive partial hand prosthesis that is made from an existing
					 mold or a cosmetic cover for a passive or functional hand prosthesis.
(bbbb) "Rigid" means not bending; inflexible
					 during normal use and resistant to normal use forces.
(cccc) "Sacroiliac Orthosis" means an
					 orthosis that traverses the pelvic and sacral areas.
(dddd) "Scoliosis Orthosis" means the same as
					 scoliosis procedure.
(eeee)
					 "Scoliosis Procedure" means a spinal orthosis that treats a curvature or other
					 instability of the spine.
(ffff)
					 "Semi-Rigid" means partially rigid; having some rigid elements.
(gggg) "Services" means activities, including
					 medical examinations, that are related to the provision of prosthetic and
					 orthotic appliances, such as repairs, laboratory work necessary for
					 construction of the appliance, casting and cast changes, realignment or
					 adjustment of appliances, application of dressings, measuring or fitting for
					 appliances, training the patient on the use and care of the appliance and
					 delivery of appliances.
(hhhh)
					 "Shoe Modification" means an addition, modification or service to an
					 off-the-shelf or custom-made shoe to improve its functionality.
(iiii) "Shoe Modifications of Stock
					 Orthopedic Shoes and Stock Conventional Shoes" means an orthotic grouping that
					 includes shoe modifications -- lifts, shoe modifications -- wedges, shoe
					 modifications -- heels, orthopedic shoe additions, and transfer or
					 replacement.
(jjjj)
					 "Shoulder-Elbow-Wrist-Hand Orthosis" means an orthotic grouping that includes
					 abduction position, custom fitted orthoses; mobile arm supports; additions to
					 mobile arm supports and fracture orthoses; or an orthosis that traverses the
					 shoulder, elbow, wrist and hand areas.
(kkkk) "Shoulder Orthosis" means an orthosis
					 that traverses the shoulder.
(llll)
					 "Spinal Orthosis" means an orthotic grouping where each individual orthosis
					 traverses some part of the spine that includes cranial orthoses, cervical and
					 multiple post collar orthoses, thoracic orthoses (rib belts), thoracic orthoses
					 (anterior-posterior-lateral-rotary control), thoracic orthoses (triplanar
					 control -- modular segmented spinal system [prefabricated]), thoracic orthoses
					 (triplanar control -- rigid frame), and thoracic orthoses (triplanar control --
					 rigid plastic shell).
(mmmm)
					 "Stock" when used with "orthopedic shoes" or "conventional shoes" means a shoe
					 that fits a patient without assembly or structural modification.
(nnnn) "Tension Based Scoliosis Orthosis"
					 means an orthosis that utilizes elastic strapping linked to control pads
					 intended for treatment of adolescent idiopathic scoliosis.
(oooo) "Thoracic-Hip-Knee-Ankle Orthosis"
					 means an orthosis that traverses the thoracic, hip, knee and ankle
					 areas.
(pppp)
					 "Thoracic-Lumbar-Sacral Orthosis" means an orthosis that traverses the
					 thoracic, lumbar and sacral areas.
(qqqq) "Thoracic Orthosis" means an orthosis
					 that traverses the thoracic area.
(rrrr) "Torsion Control Orthosis" means an
					 orthosis that controls rotation of the joint in which it traverses.
(ssss) "Truss" means an orthosis used to
					 reduce a hernia via direct external abdominal pressure.
(tttt) "Wrist-Hand-Finger Orthosis" means an
					 orthosis that traverses the wrist, hand and finger areas.
(uuuu) "Wrist-Hand Orthosis" means an
					 orthosis that traverses the wrist and hand areas.
(vvvv) "Wrist Orthosis" means an orthosis
					 that traverses the wrist.
1. New
						section filed 5-14-76 as an emergency; effective upon filing (Register 76, No.
						20).
2.
						Certificate of Compliance filed 9-8-76 (Register 76, No. 37).
3.
						Change without regulatory effect of NOTE (Register 86, No. 49).
4.
						Amendment of section heading, section and NOTE filed 10-2-2015; operative
						1-1-2016 (Register 2015, No. 40).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  10725,
						  14103.7
						  and
						  14124.5,
						  Welfare and Institutions Code. Reference: Sections
						  14103.7,
						  14105.21,
						  14131,
						  14132,
						  14133.3
						  and
						  14133.9,
						  Welfare and Institutions Code.