Updates to Clinical Coverage Policy 5B, Orthotics and Prosthetics

This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.

An amended version of Clinical Coverage Policy 5B, Orthotics and Prosthetics is posted to the NC Medicaid Program Specific Clinical Coverage Policies webpage.

Summary of Updates

Subsection 5.3.3 Helmets was divided into 5.3.3.1 Cranial Protection and 5.3.3.2 Cranial Remolding Orthosis.

In subsection 5.3.3.2 Cranial Remolding Orthosis, medical necessity criteria were updated to align with current standards of practice.

In Attachment B: Lifetime Expectancies, Quantity Limitations, and Required Provider Certifications for Orthotic and Prosthetic Devices, the following updates were made:

In Attachment C: Completing a Claim for Orthotic or Prosthetic Services, instructions about when to submit an invoice with a claim were updated to read:

Note: For manually priced items requiring PA, if the maximum allowable reimbursement was
based on a quote or estimate, then the invoice must be submitted with the claim. If the invoice was submitted with the PA request, then it is not required again with claim.

Additional Resources

The Orthotics and Prosthetics fee schedule and full text of Clinical Coverage Policy 5B, Orthotics and Prosthetics is available at NC Medicaid’s Orthotic and Prosthetic Devices webpage.

Contact

• NC Medicaid Contact Center, 888-245-0179
• Please contact health plans leveraging the information on the Health Plan Contacts and Resources page.