Prosthetics and Orthotic Devices. Benefits for external prosthetic devices (including fitting expenses) are covered when such devices are used to replace all or part of an absent body limb or to replace all or part of the function of a permanently inoperative or malfunctioning body organ. Benefits will only be provided for the initial purchase of a prosthetic device, unless the existing device cannot be repaired. Replacement devices must be prescribed by a physician because of a change in your physical condition. Benefits are provided for medically necessary shoes, inserts or orthopedic shoes. Covered services also include training and fitting. Benefits are provided as shown in the Summary of Your Costs. • Hypodermic needles, lancets, test strips, testing agents and alcohol swabs. These services are covered under the Prescription Drugs. • Supplies or equipment not primarily intended for medical use • Special or extra-cost convenience features • Items such as exercise equipment and weights • Whirlpools, whirlpool baths, portable whirlpool pumps, sauna baths and massage devices • Over bed tables, elevators, vision aids and telephone alert systems • Over the counter orthotic braces and or cranial banding • Non wearable defibrillator, trusses and ultrasonic nebulizers • Blood pressure cuff/monitor (even if prescribed by a physician) • Enuresis alarm • Compression stockings which do not require a prescription • Structural modifications to your home and/or personal vehicle • Orthopedic appliances prescribed primarily for use during participation of a sport, recreation or similar activity • Penile prostheses • Routine eye care services including eye glasses and contact lenses • Prosthetics, intraocular lenses, appliances or devices requiring surgical implantation. These items are covered under Surgery Services. Items provided and billed by a hospital are covered under the Hospital benefit for inpatient and outpatient care.
Prosthetics and Orthotic Devices. Prior Auth Required Information Information Exclusion Information Genetic Inborn Errors of Metabolism Disorders (IEM) This benefit has one or more exclusions as specified in the Exclusions section. Refer to Prior Auth R quired Prior Authorization request and e Refer to Important Information Authorization and Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) u sion This benefit has one or more exclusions as specified in the Exclusions section. Prior Auth Required Prior Auth Required CSC Call P 505‐923‐6980 1‐800‐923‐6980 Exclusion Hospital Services - Inpatient Prior Auth Required
Prosthetics and Orthotic Devices o Repair and replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices requires Prior Authorization. Repair and replacement is Covered when Medically Necessary due to change in your condition, wear or after the product’s normal life expectancy has been reached. o One-month rental of a wheelchair is Covered if you owned the wheelchair that is being repaired. • Surgical Dressing Surgical dressings that require a Practitioner’s/Provider’s prescription, and cannot be purchased over the counter, are Covered when Medically Necessary for the treatment of a wound caused by, or treated by, a surgical procedure. • Gradient compression stockings are Covered for: o Severe and persistent swollen and painful varicosities, or lymphedema/edema or venous insufficiency not responsive to simple elevation. o Venous stasis ulcers that have been treated by a Practitioner/Provider or other Health Care Professional requiring Medically Necessary debridement (wound cleaning). • Lymphedema wraps and garments prescribed under the direction of a lymphedema therapist are Covered. • Eyeglasses and Contact Lenses (Limited) The following will only be Covered: o Contact lenses are Covered for the correction of aphakia (those with no lens in the eye) or keratoconus. This includes the Eye Refraction examination. o One pair of standard (non-tinted) eyeglasses (or contact lenses if Medically Necessary) is Covered within 12 months after cataract surgery or when related to Genetic Inborn Error of Metabolism. This includes the Eye Refraction examination, lenses and standard frames. Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered except for school-aged children under 18 years old (or under 21 years of age if still attending high school): o Every 36 months per hearing impaired ear for school-aged children under 18 years old (or under 21 years of age if still attending high school). Refer to your Summary of Benefits and Coverage for your Cost Sharing (Deductible, Coinsurance and/or Copayment) amount. o Shall include fitting and dispensing services, including ear molds as necessary to maintain optimal fit, as provided by an In-network Practitioner/Provider licensed in New Mexico.
