Prior Authorization : Services Requiring Prior Authorization

Orthotics

Ankle Foot Orthotics

Most ankle foot orthotic devices do not require PA unless the frequency limitation is exceeded. The DME Index includes allowable procedure codes and associated life expectancy.

A PA request is required if a new ankle foot orthotic is needed before the life expectancy ends for the following reasons:

• A change in the member's medical needs, such as growth (the specific amount of growth must be documented in the provider's record and on the PA request), a changed foot/ankle position, or loss or gain of significant weight or height (provider must be specific in records and on the PA request).
• To replace a broken orthotic. The provider's records and the PA request must document the specific broken part or the reasons for replacement or for a different orthotic (post-surgical, etc.).

The PA request must indicate that the member will receive maximal stability in a specified area or that the orthotic device will prevent an increase in severity of a deformity.

Note: If a provider replaces an ankle foot orthotic for a fully grown adult after the one-year life expectancy has ended, PA is not required, but the provider is required to document the member's medical needs specifically in their records as listed above.

Cranial Remolding Orthoses

CRO is covered by ForwardHealth with PA.

Prior Authorization Requirements

PA requests for CRO may be approved if it is medically necessary and will be used to correct skull deformity under the following circumstances:

• The member has had surgery to treat craniosynostosis.
• The member has not had surgery to treat craniosynostosis and all of the following criteria are true:
  • The member is at least 3 months old and no more than 12 months old.
  • The member underwent at least two months of documented failed conservative therapy including home management, mechanical adjustments, and repositioning.
  • A pediatric neurosurgeon with expertise in craniofacial malformations or a craniofacial surgeon has indicated that the condition is likely to compromise normal bodily function.
  • The CRO is prescribed by a pediatric neurosurgeon with expertise in craniofacial malformations or by a craniofacial surgeon that completed an assessment and developed a treatment plan.

Prior Authorization Documentation

All of the following must be included as part of a PA request for CRO:

• A completed PA/RF.
• A completed PA/DMEA.
• Documentation that fully supports PA requirements.
• An assessment of outcome following a trial of at least two months of mechanical adjustments, home management, and repositioning. Documentation must include information on the frequency and type of conservative therapy.
• A signed and dated order from a pediatric neurosurgeon with expertise in craniofacial malformations or by a craniofacial surgeon indicating the deformity is likely to compromise normal bodily functions. The order must be dated following completion of the two-month trial.

Grant and Expiration Dates

PA will be granted for three months. If CRO is not dispensed within three months, a new PA request will need to be submitted.

Diabetic Shoes and Inserts

PA is required to exceed life expectancy for diabetic shoes and inserts. The DME Index includes allowable procedure codes and associated life expectancy.

PA requests for diabetic shoes and inserts must include the following:

• A completed PA/RF
• A completed PA/DMEA
• Documentation that fully supports the coverage criteria for diabetic shoes and inserts
• Documentation that meets the documentation requirements for diabetic shoes and inserts
• A physician prescription that meets the physician prescription requirements for diabetic shoes and inserts

Mobile Arm Supports

Mobile arm supports must be used for a trial period before a PA request is submitted.

The PA request is required to be submitted with documentation of the trial period that includes the following:

• The length of time the equipment was used on a trial basis.
• Report of the trial period to identify where it was used and the individual(s) involved in training the member how to properly use the equipment, including the credentials of the individual(s).
• Report of the member's specific functional abilities without the equipment.
• Report of the member's specific functional abilities with the use of the equipment.

If the member is involved in a therapy program to increase functional abilities, and the record of the therapy service includes the documentation required, the therapy reports may be included in the PA request.

This report of the equipment trial period is required in addition to the documentation required for all DME to support the medical necessity of the requested equipment for the specific clinical condition of the member. The PA request for the mobile arm support equipment must include the following:

• The setting(s) in which the equipment will be used.
• The transportation method that will be used, if the equipment will be transported.
• The method that will be used to store the equipment.
• The individual(s) responsible for care and maintenance of the equipment.

ForwardHealth does not allow reimbursement for rental of mobile arm supports. If reimbursement for rental of a mobile arm support system is necessary to complete the trial period, a PA request should be submitted using HCPCS procedure code E1399 (Durable medical equipment, miscellaneous).

Off-The-Shelf Orthotic Devices

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.

This PA requirement is monitored through the claims processing system. Providers should not submit a PA request if they are unsure whether the life expectancy of the device has been exceeded, unless instructed to do so through the claims processing system. Instead, providers should submit the claim for the spinal or lower extremity off-the-shelf device after the delivery of the device. If the life expectancy of the device has been exceeded, the claim will be denied and providers will be notified through an EOB code that PA is required. When notified through an EOB code that PA is required, providers should submit a PA request that includes the EOB code indicated on the claim. The PA request must be submitted within two weeks of receiving the EOB code. Providers are required to document the DOS on the PA request so that the PA can be processed correctly for reimbursement. Once the PA request is approved, the claim must be resubmitted.

Orthopedic or Corrective Shoes and Foot Orthotics

Orthopedic or corrective shoes and foot orthotics are covered by ForwardHealth with PA.

Prior Authorization Requirements

PA requirements are listed in the DME Index.

Note: PA is not always required for some procedure codes (for example, minor repairs or additions to orthopedic shoes).

Prior Authorization Documentation

The following documentation must be submitted with PA requests for orthopedic or corrective shoes or foot orthotics:

• A completed PA/RF.
• A completed PA/DMEA.
• A physician's prescription for orthopedic or corrective shoes and/or foot orthotics.
• The member's ICD diagnosis (or diagnoses) and any other co-morbid conditions that support the condition for the requested services.
• If present, the objective measurement of specific foot deformity.
• The member's height and weight.
• The shoe brand, model number, and size(s).
• Medical records from the prescribing provider that support the PA request.
• The written report of the member's podiatry exam and results.
• The member's ambulatory status and/or transfer abilities.
• The member's use of any ambulation aids for mobility, if applicable.
• Information regarding the member's functional daily routine (that is, place of residence, caregiver type, and level of assistance, if applicable).
• Specific reason for the requested service, date of initial issue of the requested service to the member, or the reason for replacement and the last DOS to member, if known.
• If new equipment is requested to replace current items, the estimate of charges to repair the member's current equipment and/or the reason repair is not possible or cost-effective.
• If mismatched shoes are requested, documentation of the foot size discrepancy.
• If custom services are requested, documentation of the services or equipment that have been tried by the member and results indicating what specific medical needs of the member were not met.