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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 4.1
Prosthetic Devices And Supplies
Issue Date:  September 19, 1990
Authority:  32 CFR 199.4(d)(3)(vii) and 10 USC 1077(a)
Revision:  C-96, January 25, 2022
1.0  HCPCS PROCEDURE CODES
Level II Codes L5000 - L9900, V2623 - V2629
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.
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