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
equipment,
as defined in 32 CFR 199.2(b), are
not covered.
Necessary bilateral prosthetics are not
considered duplicate equipment. (See the TRICARE
Operations Manual (TOM),
Chapter 17, Section 3 regarding multiple prostheses
for Active Duty Service Members (ADSMs) with major limb amputation(s).)
Note: Consistent with
TRICARE’s regulatory definition of duplicate equipment, a medically necessary
prosthetic which serves a different purpose from another prosthetic,
or a prosthetic which has essential functional differences, is not
duplicate equipment, even if the prosthetics are used for the same
limb. While in most cases only one permanent prosthetic at a time
is medically necessary, additional prosthetics may be covered when
they are medically necessary, consistent with the definitions found
in32 CFR 199.2. An example of prosthetics which
are not duplicate equipment may include foreshortened prosthetics
(sometimes called “stubbies”) that are used during ambulatory rehabilitation,
or for children for whom full-time use of fully articulating bilateral
leg prosthetics is not medically or psychologically appropriate.
In this example, the stubbies are not duplicate equipment as they
perform a separate essential function or serve a different purpose.
This example is only one of many circumstances where additional
medically necessary prosthetics may be covered. See also 32 CFR 199.2, “adequate medical documentation,”
and Chapter 1, Section 5.1 for requirements regarding medical
documentation.
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.