92-01-02-29.7. Prosthetic devices.

1. For the initial prosthesis an order is required from the primary health care provider with documentation of objective medical evidence that supports the necessity for purchase of a prosthesis directly due to the compensable work injury. a. The order must be obtained and submitted to the organization prior to consideration of purchase. b. The order must include the date of an in-person office visit that coincides with the date of the order and a specific description of the type of prosthesis being requested.

2. An injured employee shall undergo an evaluation and assessment by a treating provider, therapist, or prosthetist and that evaluation must contain recommendations based on medical necessity and conform to the primary health care provider's order.

3. The organization may require additional assessments to determine the functional levels of an injured employee who is being considered for the prosthesis.

4. The organization will purchase and maintain a single prosthesis per affected limb absent extraordinary circumstances. Extraordinary circumstances are determined by the organization in its sole discretion. Extraordinary circumstances may not be supported by nonwork activities.

5. The prosthesis must be a body-powered device absent extraordinary circumstances. Extraordinary circumstances are determined by the organization in its sole discretion. Extraordinary circumstances may not be supported by nonwork activities.

6. The organization shall approve the prosthesis prior to purchase. If the prosthesis is approved, the organization shall compensate the medical services provider according to the appropriate fee schedule.

7. Repurchase or repair of a prosthesis must be determined by the organization in its sole discretion.

8. Replacement requests for a prosthesis must meet independently the criteria in this section.

9. A minimum of two itemized cost quotes may be requested by the organization. The organization may decrease or add the number of cost quotes required.

10. An appeal of a decision made by the organization under this section must be adjudicated pursuant to North Dakota Century Code section 65-02-20.

History: Effective January 1, 2024; amended effective January 1, 2026.

Law Implemented: NDCC 65-02-20, 65-05-07