Orthotic and prosthetic devices for replacement or support of a body part

What's Covered

Medicare Part B covers orthotic and prosthetic devices including: 

·        artificial limbs and eyes

·        braces for arm, leg, back, and neck

·        breast prostheses and related supplies following a mastectomy.

·        orthopedic shoes if they're a medically necessary part of an orthotic leg brace. Prosthetic shoes are covered if they're an integral part of a prosthesis for patients with a partial foot amputation.

Medicare Orthotics: Defined

Orthotic devices are primarily covered under Medicare Part B.

As with all Medicare Part B services, covered orthotics must be reasonable and necessary for the diagnosis or treatment of an illness or injury.

In order to meet Health Care Financing Administration (HCFA) coverage requirements, an orthotic must be a rigid or semi-rigid device used either to support a weak or deformed member or to restrict or eliminate motion in a diseased or injured part of the body.

Orthotic claims must have a prescription and/ or a certificate of medical necessity signed by a physician.

Orthotic devices are defined as one of three types:

1. Custom fitted, which require substantial adjustments to a prefabricated item by a specially trained professional to meet the needs and/or unique shape of an individual patient

2. Custom fabricated, which are made for a specific patient from his/her individualized measurements and/ or pattern; or

3. Molded to patient model, whereby a cast is made of the specified body part and is used to create an orthotic device.

Some orthotics may also have additional components, which are billed separately. For example, an ankle-foot orthotics may require special strap, joints, or linings and are therefore billed in addition to the basic device.

Medicare Advantage plan:

Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for orthotics and prosthetics, contact the staff at Jacksonville Home Medical Supplies, or check with the plan directly.