Prosthetics and Orthotics

• Breast Prosthesis, Custom
• Breast Prosthesis, Mastectomy Bra
• Compression Stockings
• External Power Prosthesis
• Foot Orthotics
• Knee Orthosis
• Lower Limb Prosthesis
• Lower Limb Prosthesis, Computerized (C-Leg)
• Prosthesis
• Scoliosis Orthosis
• X-Finger Prosthesis
• Non-covered

Coverage is not guaranteed. Benefits for any service should be verified before a service is performed. Any item supplied through the facility will be billed by the facility. The supplier will not be allowed to bill these services or items separately.

Foot Orthotics

Foot Orthotics (custom made ) would meet coverage criteria for the following indications:

Click here to view the medical policy for Foot Orthotics.

Knee Orthosis

Knee Orthosis, Molded Plastic, Polycentric Knee Joints, Pneumatic Knee Pads (CTI), Custom-Fabricated

If verification indicates a brace is being used in daily activity other than sports activities, benefits will be provided according to contract benefits.

Lower Limb Prosthesis

Click here to view the medical policy for Lower Limb Prosthesis.

Lower Limb Prosthesis, Computerized (C-Leg)

Click here to view the medical policy for Computerized Lower Limb Prosthesis.

Breast Prosthesis, Custom

Benefits not routinely provided. Medical justification from prescribing physician is required.

Breast Prosthesis, Mastectomy Bra

Coverage criteria:

• Specific group benefits may apply.
• Benefits provided for up to four per year for mastectomy patients. Prostheses are replaced as meeting medical criteria for coverage

Compression Stockings

Coverage criteria:

Six pair per year are covered.

Regular support or surgical stockings are not covered unless the contract is BellSouth; covered surgical stockings are limited to two pair per calendar year if prescribed by a physician.

External Power Prosthesis

Click here to view the medical policy for External Power Prosthesis.

Scoliosis Orthosis

L1005 - Tension Based Scoliosis Orthosis and Accessory Pads, Includes Fitting and Adjustment

Coverage is limited to patients age 18 and under with one of the following diagnosis codes:

• 737.30
• 737.31
• 737.32
• 737.33
• 737.34
• 737.39
• 737.41
• 737.43
• 754.2

X-Finger Prosthesis

The X-Finger is an active-function artificial finger assembly designed specifically for partial finger amputees. The device allows users to regain complete control of the flexion and extension movements of an artificial finger in a self-contained device. It is designed to bend a silicone finger sheath in a realistic manner.

The X-Finger Prosthesis does not meet Blue Cross and Blue Shield of Alabama's medical criteria for coverage. Consideration is given for reimbursement of a basic component if the basic component meets medical criteria for coverage.

Non-covered

These devices do not meet Blue Cross and Blue Shield of Alabama’s medical criteria for coverage:

• Bioness NESS L300 Foot Drop System
  Bioness NESS H200 Hand Rehabilitation System
• Helio Leg Braces
• SaeboReach - The SaeboReach is a dynamic custom fabricated elbow, wrist, hand, finger orthosis. The SaeboReach consists of a combination of the SaeboFlex and a custom fabricated above elbow component. The orthosis features an elbow extension system. The elbow extension system provides assistance in straightening the arm so functional reaching is possible. The SaeboReach was specifically designed for individuals that have limited hand and elbow function.