Custom-Fabricated Prosthetic Devices

HMSA will not cover custom-fabricated prosthetic devices if the patient’s activities of daily living can be met with a conventional mechanical prosthetic device. Custom-fabricated refers to an item which is individually made for a specific patient (no other patient would be able to use it) starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricated components but it involves more than trimming, bending, or making other modifications to a substantially prefabricated item. If more than one prosthetic device can be used by the member, HMSA reserves the right to approve only the least costly device.

Microprocessor-controlled Prosthetic Knees

For example, microprocessor-controlled prosthetic knees are available on the market (i.e., C-LEG by Otto Bock Orthopedic Industry). These devices are equipped with sensors that detect when the knee is in full extension and adjust the swing phase automatically, permitting a more natural walking pattern of varying speeds. The devices also are designed to improve stance control.

Conventional mechanical prosthetic devices are generally adequate to accomplish the activities of daily living. Available data are inadequate to define expected improvement in health outcomes related to the increased sophistication of the devices as compared to conventional mechanical prosthetic devices. At this time HMSA will not cover microprocessor-controlled components.

Precertification

Precertification is required for prosthetic devices exceeding $10,000 in cost. To prevent misunderstandings about coverage, please contact HMSA for a benefit determination prior to ordering a custom-fabricated prosthetic device. See Benefit Information for instructions.

Revision History