Section 51315 - Amount, Scope, Duration, Limitation and Prior Authorization of Benefits for Orthotic and Prosthetic Appliances and Services(a) Orthotic and prosthetic appliances and services, to the extent necessary for the restoration of function or replacement of a body part(s), or to support a weakened or deformed body member, are covered under the Medi-Cal program as follows: (1) Except as specified in subsection (a)(2), and subject to Welfare and Institutions Code, Section 14131.10, which excludes coverage for podiatric and adult dental services (with exemptions), when prescribed by a licensed physician, a licensed podiatrist, a licensed dentist or a licensed non-physician medical practitioner, within the scope of their license, and furnished by a certified orthotist, a certified prosthetist, a certified orthotist/prosthetist, a licensed physician, a licensed dentist, a licensed podiatrist or a certified pharmacy pursuant to subsection (a)(3) below. A certified orthotist, prosthetist and orthotist/prosthetist shall hold current certification from The American Board for Certification in Orthotics, Prosthetics and Pedorthics or the Board of Certification/Accreditation or their successor organizations.(2) Stock orthopedic and stock conventional shoes, pursuant to Section 51315.1(k)(3)(A), are covered when prescribed by a licensed physician or a licensed podiatrist and furnished by a certified orthotist, a certified prosthetist or a certified orthotist/prosthetist.(3) Orthotic and prosthetic appliances and services listed in the Medi-Cal provider manual, pursuant to Welfare and Institutions Code Section 14105.21, may be furnished and billed by pharmacies, when the pharmacy is certified and enrolled in the Medi-Cal program as a provider.(b) A written prescription signed by a licensed physician, a licensed podiatrist, a licensed dentist or a licensed non-physician medical practitioner, and clinical notes/medical professional records that document the medical necessity of the appliance or service, shall be maintained by the provider in the patient's medical record, pursuant to Section 51476. A copy of the written, signed prescription or the electronic image/data transmission prescription in accordance with Health and Safety Code, Section 11027 and documentation of medical necessity, as specified in subsection (c), shall accompany the request for prior authorization, which is required under the following circumstances: (1) For orthotic appliances each time the cumulative costs of purchase, replacement, and repair exceed $250.00 per patient, per provider, per 90-day period. This 90-day period of time shall begin on the date of the first service after the close of the previous 90-day period of time during which a service, if any, was provided.(2) For prosthetic appliances each time the cumulative costs of purchase, replacement, and repair exceed $500.00 per patient, per provider, per 90-day period. This 90-day period of time shall begin on the date of the first service after the close of the previous 90-day period of time during which a service, if any, was provided.(3) For orthotic and prosthetic appliances and services where there is no allowable listed procedure code or rate of reimbursement pursuant to Welfare and Institutions Code Section 14105.21(c).(c) The prior authorization request for orthotic and prosthetic appliances and services shall be authorized when documentation includes the type of appliance or service; the medical diagnosis, and prognosis; an explanation of the purpose for the appliance or service; and substantiation that the criteria specified in subsection (c)(1) through (5) below, and the criteria specified in Section 51315.1 for orthotic appliances and services, or the criteria specified in Section 51315.2 for prosthetic appliances and services are met. (1) The appliance or service is medically necessary for the restoration of bodily functions, to support a weakened or deformed body member or for the replacement of a body part and is reasonable and necessary to protect life, to prevent significant illness or disability, or to alleviate severe pain.(2) The appliance or service is essential to performing activities of daily living or instrumental activities of daily living.(3) The appliance or service is consistent with the patient's previous abilities and limitations, as they relate to activities of daily living or instrumental activities of daily living, prior to the onset of disability or injury, or as appropriate to the patient's chronological and developmental age.(4) The appliance or service is consistent with the patient's overall medical condition.(5) The appliance or service is the lowest cost appliance or service that meets the patient's medical need(s).(d) Prior authorization of orthotic and prosthetic appliances and services shall not be granted for any of the following:(1) Backup appliances, except when the primary appliance must be worn by the patient 24 hours per day or when the appliance must be cleaned on a regular basis and cannot be dried overnight.(2) Appliances or services for the sole purpose of cosmetic restoration in the absence of medical necessity as described in subsection (c)(1).(3) Appliances or services for the sole purpose of restoring functions beyond activities of daily living or instrumental activities of daily living, such as athletic activities.(4) Appliances or services when the appliance or service is a benefit that is included as part of the acute inpatient hospital stay and the date of service occurs during that stay.(5) Repair of an appliance when the repair cost is equal to, or greater than, the cost of purchasing a new appliance.(6) Purchase or replacement of an appliance when the patient's existing appliance can be repaired at a cost less than the cost of purchasing a new appliance, unless the existing appliance does not meet the patient's medical need(s), as documented by the licensed physician, licensed podiatrist, licensed dentist or licensed non-physician medical practitioner.(7) Fitting, measuring, training or delivery of the appliance separate from the prior authorization of the appliance itself.(e) Reimbursement for orthotic and prosthetic appliances and services shall be subject to the following:(1) Shall not exceed 80 percent of the lowest maximum allowance for California established by the federal Medicare program for the same or similar appliances or services.(2) When there is no comparable Medicare-reimbursed appliance or service, reimbursement shall not exceed an amount that is the lowest of:(A) The usual charges made to the general public for the provision of the same or similar appliances or services, or(B) The maximum reimbursement rates listed in the Medi-Cal provider manual.(3) Maximum reimbursement rates are for the base appliance and for any component parts that may be added to the base appliance. When applicable, billings shall include both the base appliance and the component parts necessary to complete the prescribed appliance.(4) Orthotic and prosthetic appliances and services that do not require prior authorization shall meet the requirements under Section 51315(c).Cal. Code Regs. Tit. 22, § 51315
1. Amendment of subsection (a) filed 5-30-78; designated effective 7-1-78 (Register 78, No. 22). For prior history, see Register 77, No. 50.
2. Amendment of subsection (d) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
3. Amendment of subsection (a) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
4. Change without regulatory effect of NOTE (Register 86, No. 49).
5. Amendment of subsection (a) filed 5-25-89; operative 6-24-89 (Register 89, No. 21.)
6. Amendment of subsection (a) and NOTE, designation and amendment of subsections (a)(1)(A) and (B), and new subsections (a)(1) and (a)(2)-(a)(2)(B) filed 9-14-92; operative 10-14-92 (Register 92, No. 38).
7. Amendment of subsections (a)(2)-(a)(2)(B) filed 3-24-93; operative 4-23-93 (Register 93, No. 13).
8. Change without regulatory effect amending subsection (a)(2) and NOTE filed 3-8-94 pursuant to title 1, section 100, California Code of Regulations (Register 94, No. 10).
9. Editorial correction reinstating inadvertently omitted subsections (b)-(d)(2) (Register 97, No. 37).
10. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed 7-17-2003 as an emergency; operative 7-17-2003 (Register 2003, No. 29). A Certificate of Compliance must be transmitted to OAL by 1-13-2004 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of HISTORY 10 (Register 2003, No. 33).
12. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of NOTE filed 1-14-2004 as an emergency; operative 1-14-2004 (Register 2004, No. 3). A Certificate of Compliance must be transmitted to OAL by 7-12-2004 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 1-14-2004 order, including further amendment of subsections (a)-(a)(2), new subsections (e)-(f)(4) and amendment of NOTE, transmitted to OAL 7-12-2004 and filed 8-12-2004 (Register 2004, No. 33).
14. 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, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14103.7, 14105, 14105.21, 14132, 14132.10, 14132.765, 14133, 14133.1, 14133.3 and 14133.9, Welfare and Institutions Code.
1. Amendment of subsection (a) filed 5-30-78; designated effective 7-1-78 (Register 78, No. 22). For prior history, see Register 77, No. 50.
2. Amendment of subsection (d) filed 1-16-80; effective thirtieth day thereafter (Register 80, No. 3).
3. Amendment of subsection (a) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
4. Change without regulatory effect of NOTE (Register 86, No. 49).
5. Amendment of subsection (a) filed 5-25-89; operative 6-24-89 (Register 89, No. 21.)
6. Amendment of subsection (a) and Note, designation and amendment of subsections (a)(1)(A) and (B), and new subsections (a)(1) and (a)(2)-(a)(2)(B) filed 9-14-92; operative 10-14-92 (Register 92, No. 38).
7. Amendment of subsections (a)(2)-(a)(2)(B) filed 3-24-93; operative 4-23-93 (Register 93, No. 13).
8. Change without regulatory effect amending subsection (a)(2) and Note filed 3-8-94 pursuant to title 1, section 100, California Code of Regulations (Register 94, No. 10).
9. Editorial correction reinstating inadvertently omitted subsections (b)-(d)(2) (Register 97, No. 37).
10. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of Note filed 7-17-2003 as an emergency; operative 7-17-2003 (Register 2003, No. 29). A Certificate of Compliance must be transmitted to OAL by 1-13-2004 or emergency language will be repealed by operation of law on the following day.
11. Editorial correction of History 10 (Register 2003, No. 33).
12. Amendment of subsection (a), repealer of subsections (a)(1)-(2), redesignation and amendment of former subsections (a)(2)(A)-(B) as new subsections (a)(1)-(2), new subsection (a)(3) and amendment of Note filed 1-14-2004 as an emergency; operative 1-14-2004 (Register 2004, No. 3). A Certificate of Compliance must be transmitted to OAL by 7-12-2004 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 1-14-2004 order, including further amendment of subsections (a)-(a)(2), new subsections (e)-(f)(4) and amendment of Note, transmitted to OAL 7-12-2004 and filed 8-12-2004 (Register 2004, No. 33).
14. Amendment of section heading, section and Note filed 10-2-2015; operative 1/1/2016 (Register 2015, No. 40).