Ala. Admin. Code r. 560-X-13-.18

Current through Register Vol. 42, No. 12, September 30, 2024

Section 560-X-13-.18 - Basic Level Prosthetics, Orthotics, And Pedorthics

(1) Basic level prosthetics, orthotics and pedorthics are covered benefits to Medicaid eligible recipients up to age 65 in a non-institutional and institutional setting. The recipients must meet established Medicaid criteria applicable to prosthetic, orthotic, and pedorthic devices pursuant to this chapter and Chapter 14, DME, of the Medicaid Provider Manual.

(a) For items to be covered, recipients must meet eligibility requirements, the devices must be reasonable and necessary to improve the functioning of a malformed body member or replace an absent body member, and meet all other applicable Medicaid statutory and regulatory requirements.

(b) Providers of prosthetic, orthotic, and pedorthic devices for adults must be enrolled as a Medicaid provider and licensed by the Alabama Board of Prosthetics, Orthotics and Pedorthics.

(c) The provider must be practicing as a prosthetic, orthotic, or pedorthic practitioner in the State of Alabama at an accredited facility.

(d) Provider must keep a copy of the written prescription or order from the primary physician for the prosthetic or orthotic device in the recipient's file for a period of three years plus the current year.

(e) The provider must have documentation of the education follow-up provided to the recipient of the use of the prosthetic and orthotic device in the recipient's file.

(2) For Medicaid to approve lower limb prosthesis, medical documentation must be submitted substantiating that a prosthesis is essential in order for the recipient to ambulate and that the recipient is motivated to ambulate.

(3) For Medicaid to approve an orthotic device, medical documentation must be submitted to show that the device supports or aligns movable parts of the body, prevents or corrects deformities, or improved functioning.

(4) For Medicaid to approve therapeutic shoes for diabetes, medical documentation must be maintained showing that the recipient has diabetes mellitus and other medical conditions justifying the need. Refer to the DME Fee Schedule on the Alabama Medicaid Agency website for Prosthetic, Orthotics, and Pedorthic reimbursement rates and benefit limits.

Ala. Admin. Code r. 560-X-13-.18

New Rule: Filed February 11, 2008; effective March 17, 2008. Amended: Filed December 30, 2008; effective February 3, 2009. Amended: Filed May 11, 2012; effective June 15, 2012.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Author: Kellie Littlejohn Newman, PharmD, Director, Clinical Services

Statutory Authority: State Plan Attachments 3.1-A and 4.19-B; 42 CFR, Section 440.70 ; Title XIX, Social Security Act.