6.0 Medical Supplies and Equipment
Prosthetics Benefits and Criteria

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Prosthetics Benefit Categories:

• 6.1 Breast prostheses
• 6.2 Eye prostheses (ocular)
• 6.3 Limb prostheses
• 6.4 Prosthetics supplies

See the Prosthetics Benefit List for a full list of eligible products, prior approval requirements and frequency limitations.

For information on policies regarding the provision of orthotics and custom footwear, please consult the Provider Guide for Medical Supplies and Equipment.

Prosthetics Benefit List

 

6.1 Breast Prosthesis

Breast Prosthesis

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Brassiere (Breast Prosthesis)	99400002	Yes	2 per 2 years
Breast Prosthesis, right	99400800	Yes	2 years
Breast Prosthesis, left	99400801	Yes	2 years
Partial Breast Prosthesis	99400003	Yes	2 years

 

6.2 Eye Prosthesis (ocular)

Eye Prosthesis (ocular)

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Adjustment for Eye Prosthesis	99400830	Yes	1 year
Eye Prosthesis, left	99400005	Yes	3 years
Eye Prosthesis, right	99400006	Yes	3 years
Eye Prosthesis-Polishing	99400007	No	1 year
Scleral Shell, left	99400802	Yes	3 years
Scleral Shell, right	99400803	Yes	3 years

6.3 Limb Prostheses

Prosthetics - Limbs - Lower Extremity - Definitive

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Ankle disarticulation, left	99400014	Yes	3 years
Ankle disarticulation, right	99400015	Yes	3 years
Hemi-pelvectomy or Hip disarticulation, left	99400022	Yes	3 years
Hemi-pelvectomy or Hip disarticulation, right	99400023	Yes	3 years
Knee disarticulation (through knee), right	99400019	Yes	3 years
Knee disarticulation (through knee), left	99400018	Yes	3 years
Partial foot - shoe insert, left	99400008	Yes	3 years
Partial foot - shoe insert, right	99400009	Yes	3 years
Partial foot - tibial tubercle height, left	99400010	Yes	3 years
Partial foot - tibial tubercle height, right	99400011	Yes	3 years
Partial foot, patella tendon bearing, left	99400012	Yes	3 years
Partial foot, patella tendon bearing, right	99400013	Yes	3 years
Prosthesis, Repairs-Prosthetic, lower limb	99400024	Yes
Replace foot for AK & BK, left	99400831	Yes	3 years
Replace foot for AK & BK, right	99400832	Yes	3 years
Replace socket for AK & BK, left	99400833	Yes	3 years
Replace socket for AK & BK, right	99400834	Yes	3 years
Trans femoral - above knee, left	99400020	Yes	3 years
Trans femoral - above knee, right	99400021	Yes	3 years
Trans tibial - below knee, left	99400016	Yes	3 years
Trans tibial - below knee, right	99400017	Yes	3 years

Prosthetics - Limbs - Lower Extremity - Preparatory

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Ankle disarticulation, left	99400553	Yes
Ankle disarticulation, right	99400554	Yes
Hemi-pelvectomy or Hip disarticulation, left	99400561	Yes
Hemi-pelvectomy or Hip disarticulation, right	99400562	Yes
Knee disarticulation, left	99400557	Yes
Knee disarticulation, right	99400558	Yes
Trans femoral, left	99400559	Yes
Trans femoral, right	99400560	Yes
Trans tibial, left	99400555	Yes
Trans tibial, right	99400556	Yes

 

Prosthetics - Limbs - Upper Extremity

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Elbow disarticulation, left	99400033	Yes	3 years
Elbow disarticulation, right	99400034	Yes	3 years
Finger, multiple digits, left	99400835	Yes	3 years
Finger, multiple digits, right	99400836	Yes	3 years
Finger, single digit, left	99400837	Yes	3 years
Finger, single digit, right	99400838	Yes	3 years
Fore quarter, left	99400039	Yes	3 years
Fore quarter, right	99400040	Yes	3 years
Partial hand, finger remaining, left	99400025	Yes	3 years
Partial hand, finger remaining, right	99400026	Yes	3 years
Partial hand, thumb remaining, left	99400027	Yes	3 years
Partial hand, thumb remaining, right	99400028	Yes	3 years
Prosthesis, Repairs-Prosthetic, upper limb	99400041	Yes
Shoulder disarticulation, left	99400037	Yes	3 years
Shoulder disarticulation, right	99400038	Yes	3 years
Transhumeral above elbow, left	99400035	Yes	3 years
Transhumeral above elbow, right	99400036	Yes	3 years
Transradial below elbow, left	99400031	Yes	3 years
Transradial below elbow, right	99400032	Yes	3 years
Wrist disarticulation, left	99400029	Yes	3 years
Wrist disarticulation, right	99400030	Yes	3 years

6.4 Prosthetic Supplies

Sleeves

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Suction seal suspension sleeve	99400563	Yes	6 per year
Suspension sleeve	99400172	Yes	10 per year

Liners

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Pin system suspension liners	99400043	Yes	3 per year
Prosthesis gel liners	99400042	Yes	3 per year

Sheaths

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Sheaths, regular	99400044	Yes	12 per year
Silo sheaths	99400564	Yes	8 per year
Replacement Cosmetic Hose	99400899	Yes	2 per year

Socks

Item Description	Item Code	Prior Approval	Recommended Replacement Guidelines
Gel stump socks	99400806	Yes	2 per year
Glove, standard	99400566	Yes	3 per year
Siller cotton socks, 1 ply	99400565	Yes	12 per year
Stump shrinkers	99400047	Yes	4 per year
Stump socks, regular	99400048	Yes	12 per year