HI 00610.270 Prosthetic Devices

A. General

Prosthetic devices (other than dental) which replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered only when furnished on a physician's order. Prosthetic devices include cardiac pacemakers, prosthetic lenses (see B. below), breast prostheses (including surgical brassiere) for postmastectomy patients, maxillofacial devices and devices which replace all or part of the ear or nose. A urinary collection and retention system with or without a tube would be a prosthetic device replacing bladder function in cases of permanent urinary incontinence.

Effective October 30, 1972, colostomy (and other ostomy) bags and necessary accoutrements and supplies directly related to ostomy care are covered under the prosthetic device benefit.

B. Prosthetic lenses

The term “internal body organ” includes the lens of an eye. Prostheses replacing the lens of an eye include post-surgical lenses customarily used during convalescence from eye surgery in which the lens of the eye was removed. Permanent lenses are also covered when required by an individual lacking the organic lens of the eye because of surgical removal or congenital absence.

Payment may be made for one of the following combinations of prosthetic lens to restore essentially the vision provided by the crystalline lens of the eye:

  1. 1. 

    prosthetic bifocal lenses in frames; or

  2. 2. 

    prosthetic lenses in frames for far vision, and prosthetic lenses in frames for near vision; or

  3. 3. 

    when a prosthetic contact lens (es) for far vision is proscribed (including cases of binocular and monocular aphakia) payment can be made for the contact lens (es) and prosthetic lenses in frames for near vision to be worn at the same time as the contact lens (es); and prosthetic lenses in frames to be worn when the contacts have been removed.

Payment cannot be made for cataract sunglasses obtained in addition to the regular (untinted) prosthetic lenses.

Program payment may be made for the hydrophilic soft contact lens, Soflens (polymacon) produced by Bausch and Lomb, Inc. or, effective with services furnished on or after April 30, 1974, for Hydrocurve (hefilcon A) soft contact lens produced by Soft Lenses, Inc. when prescribed as a prosthetic lens for an aphakic patient.

Coverage also extends to certain types of implanted prosthetic lenses (pseudophakoi) and the services necessary for implantation.

C. Dentures

Dentures are excluded from coverage. However, when a denture or a portion thereof is an integral part (built-in) of a covered prosthesis, it is covered as part of that prosthesis.

D. Supplies, repairs, adjustments and replacement

Payment may be made for supplies that are necessary for the effective use of a prosthetic device (e.g., batteries needed to operate a pacemaker). Adjustment of prosthetic devices required by wear or by a change in the beneficiary's condition are covered when ordered by a physician. To the extent applicable the provisions relating to the repair and replacement of durable medical equipment in HI 00610.220 are followed with respect to prosthetic devices.

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HI 00610.270 - Prosthetic Devices - 09/15/1989
Batch run: 04/03/2015