Documenting Medical Necessity for Upper Extremity Prostheses

Most payers have a guide, such as a Local Coverage Determination or Coverage Policy, outlining the requirements of medical necessity for a particular procedure or device. In the case of Upper Extremity Prostheses, there are limited policies. In reviewing the policies that do exist, the following guidelines are consistently used to define what documentation is needed to support the medical necessity of the device:

• History of present condition (e.g. date of amputation, previous device use, therapeutic interventions)
• Physical, musculoskeletal, neurological, and cognitive examination indicating person as ability to utilize a prosthesis
• Detailed description of activities of daily living, including functional limitations present without the prosthesis
• Review of OT or rehab assessment
• Absence of comorbidity that could impact ability to use an upper extremity prosthesis

All medical necessity documentation must be corroborated in a physician’s records.

What Does This Mean for You?

Check the specific medical coverage policy for the patient’s insurance prior to providing service. Then follow the criteria and document all the points requested. Speak with the evaluating physician and gather the appropriate and detailed corroborating documentation.

Össur has created several helpful reimbursement guides to assist you with documenting upper extremity prosthetic care. Be sure to ask your Ossur Representative for copies. As always, you may contact us at [email protected] for more assistance.