Covered and Noncovered Services : Covered Services and Requirements

Orthotics

An Overview

Orthoses are devices that limit or assist motion of any segment of the human body. They are designed to stabilize a weakened body part or correct a structural problem. Examples of orthotic devices are arm braces and leg braces.

The DME Index includes a list of allowable procedure codes and related limitations.

Cranial Remolding Orthoses

CRO is covered by ForwardHealth with PA.

Diabetic Shoes and Inserts

Diabetic shoes and inserts are covered by ForwardHealth for members who meet all of the following criteria:

• Have been diagnosed with diabetes (other than gestational diabetes) by a physician
• Have at least one of the following conditions in one or both feet:
  • Foot deformity
  • History of foot ulcers
  • History of calluses that could lead to foot ulcers
  • Nerve damage due to diabetes, with signs of problems with calluses
  • Partial or complete foot amputation
  • Poor circulation
• Have a comprehensive diabetes care plan and require therapeutic shoes and/or inserts because of diabetes as documented by the physician in the member's medical record.

Life Expectancy

ForwardHealth covers medically necessary diabetic shoes and/or inserts without PA at a frequency of one pair of shoes and three inserts per foot per 12 months.

Note: Reimbursement of diabetic shoes and inserts that are needed in excess of the life expectancy listed above require PA.

Diagnosis Restrictions

Reimbursement of diabetic shoes and/or inserts is covered for members who have a primary diagnosis of diabetes, with the exception of gestational diabetes. Shoes and/or inserts are not covered for members with a primary diagnosis of gestational diabetes.

Physician Prescription Requirements

A prescription for diabetic shoes and/or inserts must include:

• An ICD diagnosis that supports the medical need for the requested diabetic shoes and/or inserts
• If present, an ICD diagnosis of any other co-morbid conditions of the member that support the medical need for the requested diabetic shoes and/or inserts
• If present, an ICD diagnosis of the member's gross foot deformity and/or other conditions that justify the medical need for requested diabetic shoes and/or inserts
• The quantity to be dispensed and the length of need

If a billing provider receives an initial prescription for a service, but after assessing the member, the physician's prescription does not completely and accurately represent all of the services and items that will be issued to the member, the billing provider is responsible for obtaining a new prescription. A prescription that indicates only "refill" or "verbal order" or the phrase "orthopedic shoes," even if signed by a physician, does not meet this requirement. Wisconsin Medicaid does not accept verbal orders for diabetic shoes and/or inserts. A billing provider is required to have a current, valid, written prescription on file before the service may be issued to the member. These prescription requirements must be present on every prescription used to support the billing provider's submission of a claim or PA request.

Off-The-Shelf Orthotic Devices

CMS recognizes three distinct categories of orthotic devices: customized items, fabricated items, and off-the-shelf items. Customized and fabricated items are only reimbursable for ABC-certified orthotists, prosthetists, licensed PTs, licensed OTs, and for spinal orthotics, licensed chiropractors. Off-the-shelf items, which do not require specific provider training or expertise to dispense, are reimbursable for a broader range of provider types; however, provision of off-the-shelf orthotics must be within the provider's legal scope of practice in order to be reimbursed. Fittings for orthotic devices are not separately reimbursable.

Providers may be reimbursed for one spinal and one lower extremity off-the-shelf orthotic device per member per year without submitting a PA request. PA is required for additional spinal and lower extremity off-the-shelf orthotic devices of the same type when the life expectancy of the device has been exceeded.

Orthopedic or Corrective Shoes and Foot Orthotics

Orthopedic or corrective shoes and foot orthotics are covered with PA. Additionally, they are covered in the following situations, per Wis. Admin. Code § DHS 107.24(4)(f):

• Postsurgery conditions
• Gross deformities
• When attached to a bar or brace

Per Wis. Admin. Code § DHS 107.24(2)(c)2, the following shoes are covered:

• Mismatched shoes involving a difference of a full size or more
• Modified shoes to take into account discrepancy in limb length

Orthopedic or corrective shoes and foot orthotics are covered when medically necessary, as defined in Wis. Admin. Code § DHS 101.03(96m). Orthopedic or corrective shoes and foot orthotics are considered medically necessary by ForwardHealth when the member is ambulatory and/or routinely and consistently performs standing pivot transfers.

Physician Prescription Requirements

A prescription for orthopedic or corrective shoes or foot orthotics, and for all related services (modifications, repair, etc.), must meet the requirements stated in Wis. Admin. Code § DHS 107.02(2m)(b) and include the following:

• An ICD diagnosis that supports the medical need for the requested orthopedic or corrective shoes or foot orthotics
• If present, an ICD diagnosis of any other co-morbid conditions of the member that support the medical need for the requested orthopedic or corrective shoes or foot orthotics
• If present, an ICD diagnosis of the member's gross foot deformity and/or other conditions that justify the medical need for the orthopedic or corrective shoes or foot orthotics
• The quantity to be dispensed and the length of need

If a billing provider receives an initial prescription for a service, but after assessing the member, the physician's prescription does not completely and accurately represent all of the services and items that will be issued to the member, the billing provider is responsible for obtaining a new prescription. A prescription that indicates only "refill," "verbal order," or "orthopedic shoes," even if signed by a physician, does not meet this requirement. Wisconsin Medicaid does not accept verbal orders for orthopedic or corrective shoes or foot orthotics. A billing provider is required to have a current and valid written prescription on file before the service may be issued to the member. These prescription requirements must be present on every prescription used to support the billing provider's submission of a claim.