Policy Name:	Artificial Appliance Requests
Policy #:	MP-01-01
Code/Rule Reference:	R.C. 4123.57(B), (C); 4779.01(I); OAC 4123-6-39; 4123-6-25
Effective Date:	07/22/2013
Approved:	Freddie Johnson, Chief of Medical Services (signature on file)
Origin:	Medical Policy
Supersedes:	All policies and procedures regarding artificial appliance and self-insured prosthesis requests that predate the effective date of this policy
History:	New
Review date:	07/22/2018

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure, in compliance with R.C. 4123.57 and OAC 4123-6-39, appropriate payment of artificial appliance and repair requests and appropriate processing of self-insured artificial appliance and repair requests.

 

II. APPLICABILITY

 

This policy applies to all Managed Care Organizations (MCOs), field staff, BWC nurses and the Medical Billing and Adjustment Unit.

 

III. DEFINITIONS

 

Amputee Clinic:  an interdisciplinary group of professional providers led by a physician with a specialty in physical medicine and rehabilitation, orthopedic surgery or vascular surgery knowledgeable in the field of prosthetics and physical disabilities, comprised of members that may include a podiatrist, physical therapist, occupational therapist, kinesiotherapist, prosthetist and other medical specialists that serves individuals requiring prosthetic devices.

Artificial appliance:  Any item that replaces a body part or function of a body part of an injured worker who has received a scheduled loss or facial disfigurement award for that body part under R.C. 4123.57(B), and that The Ohio State University hospital amputee clinic, the Rehabilitation Services Commission, an amputee clinic approved by the administrator or the administrator’s designee, or a prescribing physician approved by the administrator or the administrator’s designee determines is needed by the injured worker.  Examples of artificial appliances include, but are not limited to, prosthetics, artificial eyes, wheelchairs, canes, crutches, walkers, braces, etc. 

 

Multidisciplinary Evaluation (MDE):  An independent examination that, depending on the needs of the injured worker, is conducted by a specialty physician, licensed physical or occupational therapist, and an independent prosthetist, who will consider and assess the injured worker’s current condition regarding the amputation site and prosthetic needs.  A prosthetist is considered to be independent if s/he has not provided services to the injured worker within the past two years.

 

Prosthesis:  A custom fabricated or fitted medical device that is a type of artificial appliance used to replace a missing appendage or other external body part.  It includes an artificial limb, hand, or foot, but does not include devices implanted into the body by a physician, artificial eyes, intraocular lenses, dental appliances, ostomy products, cosmetic devices such as breast prostheses, eyelashes, wigs, or other devices that do not have a significant impact on the musculoskeletal functions of the body.

IV. POLICY

 

              General Policy Statements

 

A.      It is the policy of BWC to pay for approved artificial appliance purchases or repairs:

1.          Out of the surplus fund;

2.          When the request for the artificial appliance purchase or repair meets the criteria established in State, ex. Rel. Miller v. Industrial Commission, 71 Ohio St. 3d 229 (1994)(See Miller Policy); and

3.          When the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that award.

 

B.      State Fund Claim Requests

1.          MCOs shall process state fund claim requests for artificial appliances.

2.          MCO-approved artificial appliance requests shall be paid from the surplus fund if the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that award.

3.          MCOs may utilize BWC’s self-insured policy and procedure in developing artificial appliance evaluation criteria.

4.          MCOs may staff the following artificial appliance issues with BWC: 

a.    Medical appropriateness of requested artificial appliance;

b.    Medical examination scheduling;

c.    Billing reimbursement codes.

5.          MCOs shall schedule medical examinations as set forth in paragraph IV.G.

6.          BWC shall pay travel expenses associated with an artificial appliance in accordance with the Travel Reimbursement Policy.

 

C.       Self-Insured Claim Requests

1.          BWC shall process eligible self-insured claim requests for artificial appliances if the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that award.

2.          BWC shall reimburse prior authorized travel expenses associated with an artificial appliance processed under IV.C.1 out of the surplus fund.  See Travel Reimbursement Policy.

3.          Artificial appliance requests that BWC determines do not arise under the provisions of R.C. 4123.57(B) shall not be processed by BWC and shall be returned to the self-insured employer for processing.

 

D.      Self-insured employers requesting BWC processing of artificial appliance requests shall submit all of the following to BWC:

1.          Written evidence of payment to the injured worker of a scheduled loss or facial disfigurement award under R.C. 4123.57(B) for the body part for which an artificial appliance is being requested.

2.          Sufficient medical and claim information for BWC to process a request for an artificial appliance.

 

E.       BWC shall ensure that the following information is available for processing an artificial appliance request and may contact the provider(s) and/or prosthetist to obtain the information if necessary:

1.          Written evidence that an artificial appliance has been determined to be medically necessary for the injured worker from one of the following:

a.    The Ohio State University hospital amputee clinic;

b.    The Rehabilitation Services Commission;

c.    An amputee clinic approved by the administrator or the administrator’s designee;

d.    A prescribing physician approved by the administrator or the administrator’s designee.

2.          Dated and signed prescription of the item being requested including the manufacturer, brand name and model number;

3.          Recent physical examination that includes a functional assessment with current and expected ability, impact upon activities of daily living, assistive devices utilized and co-morbidities that impact the use of the prescribed artificial appliance;

4.          Clinical rationale for requested artificial appliance, replacement part(s) or repair(s) and a description of any labor involved;

5.          Coding description for the artificial appliance or repair utilizing the healthcare common procedure coding system (HCPCS).  If a miscellaneous code is requested, all component items bundled in the miscellaneous code shall be listed along with a complete description and itemization of charges;

6.          Copy of the manufacturer’s price list for items requested under a miscellaneous HCPCS code; and

7.          Copy of any warranties related to the requested artificial appliance.

 

F.       It is the prosthetist’s responsibility to assure that any prosthetic device fits properly for three months from the date of dispensing.  Any modifications, adjustments or replacements within the three months are the responsibility of the prosthetist who supplied the item and BWC will not reimburse for those services.  The provision of these services by another provider will not be separately reimbursed.

 

G.    Medical Examinations

1.       BWC (for self-insuring employer requests) shall, and the MCO (for state fund requests) may, schedule a multidisciplinary examination (MDE) for prosthetics or an independent medical examination (IME) for all other requests if:

a.       A requested artificial appliance has not been available on the United States market for at least two years; or

b.       In all cases that a physician review recommends an MDE or IME.

2.       BWC (for self-insuring employer requests) shall, and the MCO (for state fund requests) may, schedule a MDE for the following prosthesis claim requests:

a.       All initial multi-articulating hands or finger component prostheses;

b.       All initial microprocessor knees and feet; 

c.       Requests for replacement knees and feet microprocessor components when any of the following apply:

i.       Microprocessor components are still under warranty;

ii.     Documentation evidences non-use of the prosthesis by the injured worker;

iii.    Documentation evidences that replacement is inappropriate due to a change in medical condition;

d.       All initial custom silicone restorative passive devices;

e.       Requests for replacement of custom silicone passive devices when either of the following apply:

i.       Documentation evidences non-use of the prosthesis by the injured worker;

ii.     Documentation establishes that replacement is inappropriate due to a change in medical condition;

f.        Cases with a history of five or more repairs and/or modifications of the prosthesis within the past twelve months;

g.       Cases involving requests for authorization for specialized surgical intervention relating to external/augmented prosthetic control (e.g., targeted muscle reinnervations), skeletal attachment (e.g., osteointegration) or similar new or advanced technology.

3.       BWC (for self-insuring employer requests) and the MCO (for state fund requests) may schedule an MDE or an IME for individuals requesting an artificial appliance or artificial appliance repair that are not subject to the provisions of IV.G.1. or IV.G.2., above.

 

BWC staff may refer to the corresponding procedure for this policy entitled “Procedure for Artificial Appliance Requests” for further guidance.

 

Procedure Name:	Procedures for Artificial Appliance Requests
Procedure #:	MP-16-01.PR1
Policy # Reference:	MP-01-01
Effective Date:	07/22/2013
Approved:	Freddie Johnson, Chief of Medical Services (signature on file)
Supersedes:	All policies and procedures regarding artificial appliance and self-insured prosthesis requests that predate the effective date of this procedure
History:	New
Review date:	07/22/2018

 

 

II.      BWC staff shall refer to the Standard Claim File Documentation policy and procedure for claim-note requirements and shall follow any other specific instructions included in this procedure.

 

III.    State Fund Claim Requests

 

A.      Managed Care Organizations (MCOs) process state fund requests for artificial appliances, replacement part(s) or repair thereof if the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that award, and may request BWC staffing of the following issues relating to artificial appliance requests:

1.       Medical appropriateness of requested artificial appliance;

2.       Medical examination scheduling;

3.       Billing reimbursement codes.

 

B.      MCOs shall direct staffing requests, noting the injured worker’s (IW) name and claim number, to:

1.     BWC staff assigned to the claim; or

2.     BWC catastrophic (CAT) nurse via email to: BWC.catnurse@bwc.state.oh.us.

 

C.       BWC staff shall respond to the staffing request or forward it to the appropriate CAT nurse for response.

 

D.      MCOs are responsible for processing payment requests for MCO-approved artificial appliances in accordance with Medical Billing and Adjustment Unit processing requirements.

 

E.       MCOs shall forward travel reimbursement requests to BWC for processing.

 

IV.    Self-Insured (SI) Claim Requests

 

A.      Field staff reviewing a request for an artificial appliance, replacement part or repair thereof, shall process the request if the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that award.

1.     Field staff shall request additional documentation from the employer if insufficient documentation has been received to make a determination.

2.     Field staff may consult with their local BWC attorney for assistance, if necessary, in determining whether the injured worker’s need arises out of the award under R.C. 4123.57(B).

3.     Field staff shall return the request to the self-insured employer for processing if the requirements of this paragraph are not met and shall note in the claim file the decision rationale.

 

B.      Once a decision is made to process the request, field staff shall:

1.     Send an email to the CAT nurse (BWC.catnurse@bwc.state.oh.us) with the IW’s name and claim number.  Field staff process the request and shall work with the CAT nurse as noted.

2.     Document that the following are met prior to approving the artificial appliance, replacement part or repair:

a.       The necessity for the artificial appliance was identified in writing by one of the following:

i.         The Ohio State University hospital amputee clinic;

ii.       The Rehabilitation Services Commission;

iii.     An amputee clinic approved by the administrator or the administrator’s designee;

iv.     A prescribing physician approved by the administrator or the administrator’s designee.

b.       The Miller criteria are satisfied. (Refer to the Miller Policy). The following information will assist in determining whether Miller criteria are satisfied:

i.         From the physician of record:

a)       A detailed written order that is signed and dated and includes:

i)        The individual’s name and claim number;

ii)       Narrative condition/description;

iii)     Dated prescription;

iv)     Description of the item being requested including the manufacturer, brand name, model number;

b)      Medical documentation supporting the necessity of the requested item reflecting:

i)        Amputation history (if relevant), therapeutic intervention, clinical course and treatment plan;

ii)       Recent physical examination that includes a functional assessment and impact upon activities of daily living (if relevant), assistive devices utilized and co-morbidities that impact the use of prescribed artificial appliance;

ii.       From the prosthetist (if a prosthesis is requested):

a)       Medical documentation supporting the necessity of the requested item;

b)      If relevant, dated and signed records documenting current and expected functional ability with an explanation of any difference.  Lower limb prosthesis may utilize Medicare Functional Classification Levels (K-levels) to express functional ability;

c)       Dated and signed medical records reflecting office visits and clinical rationale for the requested prosthesis, replacement part(s) or repair(s) and description of any labor involved;

iii.     A coding description for the artificial appliance, replacement part(s) or repairs(s) utilizing the healthcare common procedure coding system (HCPCS).  If a miscellaneous code or by report (BR) code is requested, all component items bundled in the miscellaneous or BR code listed along with a complete description and itemization of charges;

iv.     Manufacturer’s price list for items requested under a miscellaneous or BR code;

v.       Warranties related to the requested artificial appliance.

3.     If information set forth in III.B.2. is not in the provided medical records, field staff shall contact the provider and/or prosthetist to obtain the necessary information.

 

C.       Artificial appliance requests meeting the criteria set forth in paragraph III.B. may be approved. Field staff shall complete the following when approving:

1.     Staff the billing reimbursement codes with the CAT nurse.  If there are questions relating to requested codes or pricing, the CAT nurse or field staff shall contact the provider to discuss the requested codes or discrepancies between the usual and customary rate (UCR) and the amount billed.

2.     Update the claim management system with the approval, including a notation of the specific allowed codes and allowed miscellaneous or BR prices in the prior authorization screen with the allowed date range (window).

3.     Send an approval letter (C-47) to the parties noting all allowed codes and the UCR or the allowed pricing for the miscellaneous or BR codes.

a.       Upon receipt of the C-19 Service Invoice from the provider, field staff shall:

i.         Compare the allowed codes and allowed prices in the claim management system and the C-47 to the billed codes on the C-19 Service Invoice to ensure a match.

ii.       If the allowed codes and pricing and the billed codes and pricing match, field staff shall approve the invoice.

iii.     If there is a discrepancy between any of the allowed codes and pricing and the billed codes and pricing on the C-19, field staff shall additionally note in the “Remarks” block on the C-19, the following:

a)       Any code(s) that were not authorized in the C-47 letter;

b)      Any pricing discrepancies between the C-19 and the C-47.

b.       Compare the date of service on the C-19 (date of delivery of the service) to the allowed date range in the claim management system.  The service date must fall within the allowed date range.  If within the date range, field staff shall change the date range in the claim management system to the date of service on the C-19.  If the date of service is out of the allowed date range, field staff shall contact the CAT nurse.

c.       Send the C-19 to Medical Billing and Adjustments (MBA) so the bill can be paid via the surplus fund.

 

D.      Field staff may consult with the CAT nurse for assistance in reviewing an artificial appliance request.  Staffing will result in one of the following:

1.     The request will be pended:  field staff shall send an additional request for documentation.

2.     The request will be denied:  field staff shall update the claim management system and issue a denial letter (C-48) to all parties.

3.     The request will be referred for physician file review or the injured worker will be scheduled for an independent medical examination (IME) or a multidisciplinary evaluation (MDE):  field staff shall notify the injured worker in writing of the scheduling of an IME or MDE.

a.       If the physician file review or multidisciplinary evaluation recommends denial of the request, field staff shall deny the request, update the claim management system, generate a C-48 and send it to all parties.

b.       If the physician file review or multidisciplinary evaluation recommends approval of the request, field staff shall approve the request and follow the provisions set forth in paragraph III.C.

 

E.       The CAT nurse may contact the physician and/or prosthetist to discuss recommended amendments to the requested artificial appliance and/or repair request.  Recommended amendments may arise from the CAT nurse, physician review recommendations and/or IME or MDE recommendations.

1.     If amendments are recommended, the CAT nurse shall request withdrawal of the original C-9 and request a revised C-9 reflecting the recommended amendments.

2.     If a revised C-9 is submitted, the CAT nurse will review it to ensure that recommended amendments were incorporated and shall forward the request to field staff to complete the approval process as set forth in III.C.2. and III.C.3.

3.     If agreement cannot be reached with the physician and/or prosthetist to withdraw and submit a revised C-9, field staff shall deny the C-9 request, update the claim management system and send a C-48 to all parties.

 

V.      BWC staff (for SI employer requests) shall schedule Multidisciplinary Evaluations and/or Independent Medical Examinations as follows:

 

A.      The BWC CAT nurse shall schedule an:

1.      MDE for prosthetics if:

a.       A requested prosthetic has not been available on the United States market for at least two years;

b.       A physician review recommends an MDE; or

c.       One of the following is requested:

i.         All initial multi-articulating hands or finger component prostheses;

ii.       All initial microprocessor knees and feet;

iii.     Requests for replacement knees and feet microprocessor components when any of the following apply:

a)       Microprocessor components are still under warranty;

b)      Documentation evidences non-use of the prosthesis by the injured worker;

c)       Documentation evidences that replacement is inappropriate due to a change in medical condition;

iv. All initial custom silicone restorative passive devices;

v. Requests for replacement of custom silicone passive devices when either of the following apply:

a)    Documentation evidences non-use of the prosthesis by the injured worker;

b)    Documentation establishes that replacement is inappropriate due to a change in medical condition;

vi. Cases with a history of five or more repairs and/or modifications of the prosthesis within the past twelve months;

vii. Cases involving requests for authorization for specialized surgical intervention relating to external/augmented prosthetic control (e.g., targeted muscle reinnervations), skeletal attachment (e.g., osteointegration) or similar new or advanced technology.

2.       IME for any artificial appliance if:

a.       A requested artificial appliance has not been available on the United States market for at least two years; or

b.       A physician review recommends an IME.

 

B.    The BWC CAT nurse may schedule an MDE or an IME for individuals requesting an artificial appliance or artificial appliance repair that are not subject to the provisions of IV.A.

 

VI.    The Multidisciplinary Evaluation

 

A.      MDEs shall be scheduled at an amputee clinic and, depending on the needs of the injured worker, shall be conducted by a specialty physician, licensed physical or occupational therapist, and an independent prosthetist, who will consider and assess the injured worker’s current condition regarding the amputation site and prosthetic needs.  A prosthetist is considered to be independent if he or she has not provided services to the injured worker within the past two years.

 

B.      The MDE shall include the following:

1.     A physician report including:

a.       Medical history;

b.       History and physical;

c.       Diagnostics that were reviewed;

d.       Discussion of contributory medical conditions that could be a barrier to use of the requested prosthetic device;

e.       Discussion of current condition of the amputation site and residual limb; and

f.        Current functional status and expected potential.

2.     A physical or occupational therapist report including:

a.       Current functional status; and

b.       Expected functional outcome.

3.     A prosthetist report including:

a.       Prior prosthetic use, if applicable;

b.       Current functional status;

c.       Expected functional outcome;

d.       HCPCS coding of the recommended device or repair; and

e.       Manufacturer list pricing of the recommended device.

 

C.       Staff shall provide relevant information available in the claim file to the clinic performing the MDE, shall inform the clinic of the information set forth in paragraph V.B. to be addressed through the MDE and provide any additional questions to be addressed relevant to the requested artificial appliance, replacement part(s) or repair(s).

 

D.      The provider(s) performing the MDE shall bill for services rendered in the MDE on a C-19 Service Invoice.

 

VII.  Travel Reimbursement

 

A.      Field staff (or the CAT nurse when scheduling an MDE) shall process travel reimbursement requests as set forth in the Travel Reimbursement Policy.

 

B.      Field staff shall notify the IW of the location of the travel reimbursement form (Form C-60) on ohiobwc.com and mail a form to the IW if requested.