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 4 - Scope and Duration of Benefits › Section 51315.2 - Requirements Applicable to the Prior Authorization of Prosthetic Appliances and Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prosthetic appliances and services shall be authorized
						under the Medi-Cal program when supporting documentation and all other
						requirements specified in Section
						51315 and in this section are
						met.
For purposes of this section, medical conditions cited
						with each appliance/service or group of appliances/services shall not be
						construed to represent an exhaustive list of medical conditions appropriate to
						each appliance/service or group of appliances/services. Likewise, such medical
						conditions may not be appropriate for authorization of the requested
						appliance/service if medical necessity for the specific appliance/service is
						not documented.
(a) Lower Limb
					 Prostheses:
(1) Shall be authorized when the
					 patient has a functional level of "one" or higher (potential for ambulation or
					 other functional activites). Lower limb prostheses shall not be authorized when
					 the patient has a functional level of "zero" (no potential for ambulation or
					 other functional activites).
(2)
					 Shall include all of the following:
(A)
					 Partial Foot Prostheses shall be authorized when the patient has had an
					 amputation of part or all of the foot and requires a definitive prosthesis to
					 permit ambulation or other functional activities.
(B) Ankle Prostheses shall be authorized when
					 the patient has had an amputation through or at the ankle, such as a Syme's
					 procedure and requires a definitive prosthesis to permit ambulation or other
					 functional activities.
(C) Below
					 Knee Prostheses shall be authorized when the patient has had an amputation
					 between the ankle and knee and requires an exoskeletal definitive prosthesis to
					 permit ambulation or other functional activities.
(D) Knee Disarticulation Prostheses shall be
					 authorized when the patient has had an amputation through or near the knee and
					 requires an exoskeletal definitive prosthesis to permit ambulation or other
					 functional activities.
(E) Above
					 Knee Prostheses shall be authorized when the patient has had an amputation
					 between the knee and hip and requires a definitive prosthesis to permit
					 ambulation or other functional activities.
(F) Hip Disarticulation Prostheses shall be
					 authorized when the patient has had an amputation through or near the hip and
					 requires an exoskeletal definitive prosthesis to permit ambulation or other
					 functional activities.
(G)
					 Hemipelvectomy Prostheses shall be authorized when the patient has had an
					 amputation with removal of half the pelvis and requires an exoskeletal
					 definitive prosthesis to permit ambulation or other functional
					 activities.
(H) Endoskeletal
					 Prostheses shall be authorized when the patient has had a lower limb amputation
					 and requires an endoskeletal definitive prosthesis to permit ambulation or
					 other functional activities, appropriate to the requested procedure
					 code(s).
(I) Immediate and Early
					 Post Surgical Procedures shall be authorized when the patient has had a lower
					 limb amputation and requires one or more of the following, appropriate to the
					 requested procedure code(s):
1. A temporary
					 prosthesis shall be authorized when it is applied soon after amputation before
					 the original amputation wound or residual limb revision(s) wound has completely
					 healed to permit some lower extremity function.
2. An additional cast change(s) and
					 realignment(s) of the temporary prosthesis specified in paragraph 1. above
					 shall be authorized when the patient has an existing or authorized temporary
					 prosthesis that requires these services.
3. A temporary application of a non-weight
					 bearing rigid dressing shall be authorized when it is applied soon after
					 amputation before the original amputation wound or the residual limb
					 revision(s) wound has completely healed, and when there is no expectation of
					 use of a prosthesis until the wound has completely healed.
(J) Initial Prostheses shall be authorized
					 when the patient has had a lower limb amputation that requires a temporary
					 prosthesis, and when the prosthesis is applied after the original amputation
					 wound or the residual limb revision(s) wound has healed but the residual limb
					 has not reached its final shape, appropriate to the requested procedure
					 code(s).
(K) Preparatory Prostheses
					 -- Below Knee shall be authorized when the patient has had a below-the-knee
					 amputation and requires a temporary prosthesis to permit some ambulation or
					 other functional activities in preparation for the fitting of a definitive
					 prosthesis, and when the prosthesis is applied after the original amputation
					 wound or the residual limb revision(s) wound has healed but the residual limb
					 has not reached its final shape.
(L) Preparatory Prostheses -- Above Knee
					 shall be authorized when the patient has had an above-the-knee amputation and
					 requires a temporary prosthesis to permit some ambulation or other functional
					 activities in preparation for the fitting of a definitive prosthesis, and when
					 the prosthesis is applied after the original amputation wound or the residual
					 limb revision(s) wound has healed but the residual limb has not reached its
					 final shape, appropriate to the requested procedure code(s).
(M) Additions to Lower Limb Prostheses:
1. Shall include all of the following:
a. Endoskeletal System -- Above
					 Knee.
b. Test Sockets.
c. Socket Variations.
d. Socket Inserts.
e. Suspension -- Below Knee.
f. Suspension -- Above Knee.
g. Exoskeletal Knee-Shin System.
h. Endoskeletal Knee-Shin System.
i. Miscellaneous.
2. Shall be authorized when all of the
					 following criteria are met:
a. The patient's
					 medical condition requires the specific function for which the addition(s) was
					 designed.
b. The addition(s) is
					 required by the patient to improve the functionality of the prosthesis, without
					 which the patient's medical need(s) would not be met.
c. The patient has an existing or authorized
					 lower limb prosthesis that is compatible with the
					 addition(s).
(N) Replacements -- Feet-Ankle Units shall be
					 authorized when both of the following criteria are met:
1. The cost(s) of the replacement is less
					 than the cost(s) of purchasing a new prosthesis.
2. The patient has an existing or authorized
					 lower limb prosthesis that is compatible with the
					 replacement(s).