5101:3-10-20 Covered orthotic and prosthetic services and associated limitations.

Unless otherwise specified, any provider seeking reimbursement for orthotic and prosthetic services must meet the provisions contained within Chapter 4779. of the Revised Code or be exempt from licensure under section 4779.02 of the Revised Code in order to be eligible for reimbursement for services provided.

(A) Medically necessary orthotic and prosthetic services are covered as listed in appendix A to this rule.

(B) The allowed reimbursement amount for any orthotic or prosthetic device listed in appendix A to this rule includes, but is not limited to, the following:

(1) Labor;

(2) Casting, fitting, or measuring fees;

(3) Charges for travel; and

(4) Charges for shipping and mailing.

(C) It is the provider's responsibility to assure that any orthotic or prosthetic device fits properly for three months from the date of dispensing. Any modifications, adjustments, or replacements within the three months are the responsibility of the provider that supplied the item and no additional charge may be made to the department or the consumer. The provision of these services by another provider will not be separately reimbursed.

(D) "Unlisted procedure" and "not otherwise specified (NOS)" codes require complete description and itemization of charges when being submitted for prior authorization.

(E) Coverage of repair or replacement of parts for orthotic or prosthetic devices.

(1) Orthotic devices.

(a) Prior authorization is not required for the repair or replacement of minor parts for orthotic devices, which includes the amount for labor, when the repair or replacement of the orthotic device is less than or equal to one hundred twenty dollars with the exception listed in paragraph (F) of this rule.

(b) Prior authorization is required for the repair or replacement of major parts for orthotic devices, which includes the amount for labor, when the repair or replacement of the orthotic device is greater than one hundred twenty dollars.

(c) To bill for the repair of orthotic devices or the replacement of minor or major parts for orthotic devices, the provider must bill the appropriate code listed in appendix A to this rule.

(2) Prosthetic devices.

(a) Prior authorization is not required for the repair or replacement of minor parts for prosthetic devices, which includes the amount for labor, when the repair or replacement of the prosthetic device is less than or equal to one hundred twenty dollars.

(b) Prior authorization is required for the repair or replacement of major parts for prosthetic devices, which includes the amount for labor, when the repair or replacement of the prosthetic device is greater than one hundred twenty dollars with the exception listed in paragraph (F) of this rule.

(c) To bill for the repair of prosthetic devices or the replacement of minor or major parts for prosthetic devices, the provider must bill the appropriate code listed in appendix A to this rule.

(3) Prior authorization is required for orthotic and prosthetic device repair or replacement less than or equal to one hundred twenty dollars when the repair or replacement of the orthotic or prosthetic device is in excess of one repair or replacement per consumer per one hundred twenty day period.

(4) Coverage and claims submission for the repair or replacement of parts for orthotic and prosthetic devices are subject to the requirements listed in paragraphs (A)(2) to (A)(12) of rule 5101:3-10-08 of the Administrative Code.

(F) For those codes listed in appendix A to this rule that are preceded by an asterisk, all costs of repair are included in the reimbursement amount.

(G) Preparatory prostheses will be considered for authorization when documentation is provided at the time of submission of the prior authorization. The documentation should include the reason for the amputation, the date of the amputation, and a statement of why the patient will benefit by the application of a preparatory prosthesis prior to the design of the definitive. It is recognized that not every amputee is a candidate for a preparatory prosthesis prior to the fitting of a definitive; however, he or she will be considered where unusual physical changes are anticipated or cardiovascular or other physical conditions require evaluation to determine if a patient will be successful as a user of a definitive prosthetic.

(H) Twister (torsion) cables may be approved for only the treatment of children with neuromuscular diseases, and related diagnoses. Requests for torsion cables to treat positional deformities will not be covered by the Ohio department of job and family services (ODJFS) because of anticipated resolution that occurs with maturation.

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Effective: 03/29/2012
R.C. 119.032 review dates: 03/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 3/1/84, 12/30/84, 10/1/88, 4/13/89 (Emer), 5/15/89, 5/1/90, 6/20/90 (Emer), 2/17/91, 4/1/92 (Emer), 7/1/92, 12/10/93, 12/30/93 (Emer), 3/31/94, 8/1/95, 12/29/95 (Emer), 3/21/96, 1/4/00 (Emer), 3/20/00, 12/29/00 (Emer), 3/30/01, 12/31/01 (Emer), 3/29/02 10/1/04, 11/1/04 (Emer), 1/16/05, 9/1/05, 12/30/05 (Emer), 3/27/06, 10/15/06, 12/29/06 (Emer), 3/29/07, 12/16/07, 12/31/07 (Emer), 3/30/08, 12/31/08 (Emer), 3/31/09, 12/30/10 (Emer), 3/30/11, 9/1/11, 12/30/11 (Emer)