WAC 182-543-5000 Covered—Prosthetics/orthotics.

WAC 182-543-5000 Prosthetics/orthotics.

Effective January 1, 2019

1. The medicaid agency pays for, without prior authorization (PA), the following prosthetics and orthotics. Items that meet the definition of medical equipment may be covered under the requirements for medical equipment. Prosthetics and orthotics that do not meet those definitions are covered, with stated limitations:
   1. Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - One every five years.
   2. Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - One per lifetime, per limb.
   3. Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - One per lifetime, per limb.
   4. Socket replacement, below the knee, molded to patient model - One per twelve-month period, per limb.
   5. Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - One per twelve-month period, per limb.
   6. All other prosthetics and orthotics are limited to one per twelve-month period per limb.
   7. Prosthetics and orthotics beyond these limits may be prior authorized when medically necessary, as defined in WAC 182-500-0070.
2. The agency pays only licensed prosthetic and orthotic providers to supply prosthetics and orthotics. This licensure requirement does not apply to the following:
   1. Providers who are not required to have specialized skills to provide select orthotics, but meet medical equipment and pharmacy provider licensure requirements;
   2. Occupational therapists providing orthotics who are licensed by the Washington state department of health in occupational therapy; and
   3. Out-of-state providers, who must meet the licensure requirements of that state.
3. The agency pays only for prosthetics or orthotics that are listed as such by the Centers for Medicare and Medicaid Services (CMS), that meet the definition of prosthetic or orthotic in WAC 182-543-1000 and are prescribed under WAC 182-543-1100.
4. The agency pays for repair or modification of a client's current prosthesis. To receive payment, all of the following must be met:
   1. All warranties are expired;
   2. The cost of the repair or modification is less than fifty percent of the cost of a new
      prosthesis and the provider has submitted supporting documentation; and
   3. The repair must have a warranty for a minimum of ninety days.
5. Clients are responsible for routine maintenance of their prosthetic or orthotic. If a client
   does not have the physical or mental ability to perform this task, the client's caregiver is
   responsible for routine maintenance of the prosthetic or orthotic. The agency requires PA for extensive maintenance to a prosthetic or orthotic.