1. (1) Indications and limitations of coverage and medical appropriateness:

   1. (a) The Division may cover some orthotics and prosthetics for covered conditions;
   2. (b) Use the current Healthcare Common Procedure Coding System (HCPCS) Level II Guide for current codes and descriptions;
   3. (c) For adults, follow Medicare current guidelines for determining coverage;
   4. (d) For clients under age 21, the prescribing practitioner shall determine and document medical appropriateness;
   5. (e) The hospital is responsible for reimbursing the provider for orthotics and prosthetics provided on an inpatient basis;
   6. (f) Evaluations, office visits, fittings, and materials are included in the service provided;
   7. (g) Evaluations will only be reimbursed as a separate service when the provider travels to a client’s residence to evaluate the client’s need;
   8. (h) See Division 129, Speech-Language Pathology, Audiology and Hearing Aid Services for coverage criteria for speech and audiology prosthetic devices and accessories.
   9. (i) See OAR 410-122-0658 for coverage criteria for mastectomy sleeves (L8010).

2. (2) Documentation requirements:

   1. (a) For services that require prior authorization (PA): Submit documentation for review that supports conditions of coverage as specified in this rule are met;
   2. (b) For services that do not require PA: Medical records that support conditions of coverage as specified in this rule are met shall be on file with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

3. (3) Table 122-0660-1: Codes requiring PA.

   [ED. NOTE: Tables referenced are available from the agency.]

   [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.]

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 27-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 60-2015, f. 10-29-15, cert. ef. 11-1-15
DMAP 17-2012, f. 3-30-12, cert. ef. 4-1-12
DMAP 40-2009, f. 12-15-09, cert. ef. 1-1-10
DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06
OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 25-2004, f. & cert. ef. 4-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
OMAP 11-1998, f. & cert. ef. 4-1-98
HR 7-1997, f. 2-28-97, cert. ef. 3-1-97
HR 17-1996, f. & cert. ef. 8-1-96
HR 41-1994, f. 12-30-94, cert. ef. 1-1-95
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 10-1992, f. & cert. ef. 4-1-92
HR 13-1991, f. & cert. ef. 3-1-91