2.0 DESCRIPTION
2.1 Prosthetic.
A prosthetic or prosthetic device (prosthesis) determined to be
necessary because of significant conditions resulting from trauma,
congenital anomalies, or diseases.
2.2 Prosthetic supplies. Supplies
that are necessary for the effective use of a prosthetic or prosthetic
device.
3.0 POLICY
3.1 Prosthetics,
prosthetic devices, and prosthetic supplies medically necessary
because of significant conditions resulting from trauma, congenital
anomalies, or disease are covered.
3.2 Duplicate or similar items
are not covered. Therefore, only one permanent prosthesis at a time is
covered unless a beneficiary requires bilateral prostheses.
(See
the TRICARE Operations Manual (TOM), Chapter 17, Section 3 regarding
multiple prostheses for Active Duty Service Members (ADSMs) with
major limb amputation(s).)
3.3 Prosthetics, prosthetic devices,
and supplies shall be consistent with the beneficiary’s symptoms
or confirmed diagnosis of the illness or injury under treatment,
and not in excess of the beneficiary’s needs.
3.4 Additionally,
the following are covered:
3.4.1 Any accessory or item of supply
that is used in conjunction with the device for the purpose of achieving
therapeutic benefit and proper functioning;
3.4.2 Services
necessary to train the recipient of the device in the use of the
device;
3.4.3 Repair of the device for normal wear and tear
or damage;
3.4.4 Customization of the prosthetic is covered
when provided by an otherwise authorized provider.
3.5 Replacement.
Replacement of a prosthetic is covered when:
3.5.1 Required due to growth or
a change in the patient’s condition; or
3.5.2 The device is lost or irreparably
damaged or the cost of repair would exceed 60% of the cost of replacement.
Effective September 1, 2005.
3.6 Surgical implants that are
approved for use in humans by the U.S. Food and Drug Administration
(FDA) are covered as an essential and integral part of an otherwise
covered surgical procedure.
3.7 As of May 20, 1999, the purchase
of prosthetic devices is expanded to include, but not limited to,
ears, noses, and fingers, as determined by the Secretary of Defense,
to be necessary because of significant conditions resulting from
trauma, congenital anomalies, or disease.
3.8 Prosthetic devices with an
FDA approved Investigational Device Exemption (IDE) categorized by
the FDA as non-experimental/investigational (FDA Category B) will
be considered for coverage. Coverage is dependent on the device
meeting all other requirements of the law and rules governing TRICARE
and upon the beneficiary involved meeting FDA approved IDE study
protocols.
3.9 Coverage for prosthetic devices includes myoelectric
prosthetic devices. As an example, a myoelectrical prosthesis with
a hand is an acceptable alternative to conventional prosthesis with
a hook.
4.0 EXCLUSIONS
4.1 Prosthetic
devices categorized by the FDA as experimental/investigational (FDA
Category A) IDEs.
4.2 Prosthetic devices intended
for sports related purposes, exercise equipment, physiotherapy, personal
comfort, and convenience.