How to Find Prosthetic and Orthotic Medical Policies

What You Need to Know

Commercial health plan medical policies list the coverage criteria for different prosthetic and orthotic devices. Because commercial payers are not required to follow Medicare's LCD and Policy Article requirements, you must understand how to quickly find applicable medical policies that could affect the payer's decision to authorize or approve the care you provide.

For most insurers - and for all of the "Big 5" - United Healthcare, Aetna, BCBS, Cigna, and Humana - you can typically find their prosthetic and orthotic medical policies by using the following search terms: 

• For UHC, Aetna, BCBS plans, and Cigna:"[insurer name] prosthesis medical policy""[insurer name] orthotic braces medical policy"

Note: when searching for a BCBS plan, you must be specific (e.g., "Anthem," "Carefirst," "Independence" etc.).

• For Humana: "Humana clinical practice guidelines" - once on Humana's homepage for their guidelines, you can search by care area to obtain a specific CPG.

 What this Means for You

If you want to enhance the chance of a successful claim and improve your operational efficiency, you should familiarize yourself with the relevant medical policy for the type of device you propose providing to your patient. Don't assume that because an insurer covered or excluded a service or device last year that it will do the same thing today - you need to check the current version of the medical policy and understand when it is likely to get updated next in order to avoid unwanted surprises.