Prostheses/Prosthetic Appliances and Devices Prostheses/prosthetic appliances and devices are defined as fabricated replacements for missing body parts. Prostheses/prosthetic appliances and devices include, but are not limited to: • limb prostheses; • terminal devices such as hands or hooks; • speech prostheses; and • facial prostheses. Orthoses and Orthotic Devices Orthoses and orthotic devices are defined as orthopedic appliances or apparatuses used to support, align, prevent or correct deformities. Coverage is provided for custom foot orthoses and other orthoses as follows: • Non-foot orthoses – only the following non-foot orthoses are covered: • rigid and semi-rigid custom fabricated orthoses; • semi-rigid prefabricated and flexible orthoses; and • rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints. • Custom foot orthoses – custom foot orthoses are only covered as follows: • for persons with impaired peripheral sensation and/or altered peripheral circulation (e.g. diabetic neuropathy and peripheral vascular disease); • when the foot orthosis is an integral part of a leg brace and is necessary for the proper functioning of the brace; • when the foot orthosis is for use as a replacement or substitute for missing parts of the foot (e.g. amputated toes) and is necessary for the alleviation or correction of Injury, Sickness or congenital defect; and • for persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement. The following are specifically excluded orthoses and orthotic devices: • prefabricated foot orthoses; • cranial banding and/or cranial orthoses. Other similar devices are excluded except when used postoperatively for synostotic plagiocephaly. When used for this indication, the cranial orthosis will be subject to the limitations and maximums of the External Prosthetic Appliances and Devices benefit;
• orthosis shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers; • non-foot orthoses primarily used for cosmetic rather than functional reasons; and • non-foot orthoses primarily for improved athletic performance or sports participation. Braces A Brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part. The following braces are specifically excluded: Copes scoliosis braces. Splints A Splint is defined as an appliance for preventing movement of a joint or for the fixation of displaced or movable parts. Coverage for replacement of external prosthetic appliances and devices is limited to the following: • replacement due to regular wear. Replacement for damage due to abuse or misuse by the person will not be covered. • replacement required because anatomic change has rendered the external prosthetic appliance or device ineffective. Anatomic change includes significant weight gain or loss, atrophy and/or growth. • replacement due to a surgical alteration or revision of the impacted site. Coverage for replacement is limited as follows: • no more than once every 24 months for persons 19 years of age and older. • no more than once every 12 months for persons 18 years of age and under. The following are specifically excluded external prosthetic appliances and devices: • external and internal power enhancements for external prosthetic devices; or • microprocessor controlled prostheses and orthoses; and • myoelectric prostheses and orthoses.
HC-COV1125
01-22 V1
Fertility Services • charges made for services related to: • diagnosis of infertility and treatment of infertility once a condition of infertility has been diagnosed.
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