Braces; trusses; and artifical legs, arms, and eyes are covered when furnished incident to a physician’s services or on a physician’s order. A brace includes rigid and semirigid devices used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Back braces include, but are not limited to, sacroiliac, sacrolumbar, dorsolumbar corsets, and belts. Stump stockings and harnesses (including replacements) are also covered when these appliances are essential to the effective use of an artificial limb. Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when ordered by a physician. Adjustments, repairs, and replacements are covered so long as the device continues to be medically required.
Electric hook, switch or myoelectric controlled, pediatric
Electronic elbow, hosmer or equal, switch controlled
Electronic elbow, microprocessor sequential control of elbow and terminal device
Electronic elbow, microprocessor simultaneous control of elbow and terminal device
Electronic elbow, adolescent, variety village or equal, switch controlled
Electronic elbow, child, variety village or equal, switch controlled
Electronic elbow, adolescent, variety village or equal, myoelectronically controlled
Electronic elbow, child, variety village or equal, myoelectronically controlled
Electronic wrist rotator, any type
Electronic wrist rotator, otto bock or equal
Continued
Electronic wrist rotator, for utah arm
Six volt battery, each
Battery charger, six volt, each
Twelve volt battery, each
Battery charger, twelve volt, each
Lithium ion battery, rechargeable, replacement
Lithium ion battery charger, replacement only
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)
Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material
Addition to upper extremity prosthesis, user adjustable, mechanical, residual limb volume management system (with or without lamination kit)
Upper extremity prosthesis, not otherwise specified
Repair of prosthetic device, repair or replace minor parts
Repair prosthetic device, labor component, per 15 minutes
Prosthetic donning sleeve, any material, each
Gasket or seal, for use with prosthetic socket insert, any type, each
Male vacuum erection system
Continued
Tension ring, for vacuum erection device, any type, replacement only, each
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
Breast prosthesis, mastectomy sleeve
External breast prosthesis garment, with mastectomy form, post mastectomy
Breast prosthesis, mastectomy form
Breast prosthesis, silicone or equal, without integral adhesive
Breast prosthesis, silicone or equal, with integral adhesive
Nipple prosthesis, prefabricated, reusable, any type, each
Nipple prosthesis, custom fabricated, reusable, any material, any type, each
Custom breast prosthesis, post mastectomy, molded to patient model
Breast prosthesis, not otherwise specified
Nasal prosthesis, provided by a non-physician
Midfacial prosthesis, provided by a non-physician
Orbital prosthesis, provided by a non-physician
Upper facial prosthesis, provided by a non-physician
Hemi-facial prosthesis, provided by a non-physician
Auricular prosthesis, provided by a non-physician
Partial facial prosthesis, provided by a non-physician