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.