Policy
Name:
|
Artificial
Appliance Requests
|
Policy
#:
|
MP-01-01
|
Code/Rule
Reference:
|
R.C.
4123.57(B), (C); 4779.01(I); OAC 4123-6-39; 4123-6-25
|
Effective
Date:
|
07/22/2013
|
Approved:
|
Freddie
Johnson, Chief of Medical Services (signature on file)
|
Origin:
|
Medical
Policy
|
Supersedes:
|
All
policies and procedures regarding artificial appliance and self insured
prosthesis requests that predate the effective date of this policy
|
History:
|
New
|
Review
date:
|
07/22/2018
|
I.
POLICY PURPOSE
The
purpose of this policy is to ensure, in compliance with R.C. 4123.57 and OAC
4123-6-39, appropriate payment of artificial appliance and repair requests and
appropriate processing of self insured artificial appliance and repair
requests.
II.
APPLICABILITY
This
policy applies to all Managed Care Organizations (MCOs), field staff, BWC
nurses and the Medical Billing and Adjustment Unit.
III.
DEFINITIONS
Amputee Clinic: an
interdisciplinary group of professional providers led by a physician with a
specialty in physical medicine and rehabilitation, orthopedic surgery or
vascular surgery knowledgeable in the field of prosthetics and physical
disabilities, comprised of members that may include a podiatrist, physical
therapist, occupational therapist, kinesiotherapist, prosthetist and other medical specialists that serves
individuals requiring prosthetic devices.
Artificial
appliance:
Any item that replaces a body part or function of a body part of an injured
worker who has received a scheduled loss or facial disfigurement award for that
body part under R.C. 4123.57(B), and that The Ohio State University hospital
amputee clinic, the Rehabilitation Services Commission, an amputee clinic
approved by the administrator or the administrator’s designee, or a prescribing
physician approved by the administrator or the administrator’s designee
determines is needed by the injured worker. Examples of artificial
appliances include, but are not limited to, prosthetics, artificial eyes,
wheelchairs, canes, crutches, walkers, braces, etc.
Multidisciplinary
Evaluation (MDE):
An independent examination that, depending on the needs of the injured worker,
is conducted by a specialty physician, licensed physical or occupational
therapist, and an independent prosthetist, who will
consider and assess the injured worker’s current condition regarding the
amputation site and prosthetic needs. A prosthetist
is considered to be independent if s/he has not provided services to the
injured worker within the past two years.
Prosthesis: A custom
fabricated or fitted medical device that is a type of artificial appliance used
to replace a missing appendage or other external body part. It includes an
artificial limb, hand, or foot, but does not include devices implanted into the
body by a physician, artificial eyes, intraocular lenses, dental appliances, ostomy products, cosmetic devices such as breast
prostheses, eyelashes, wigs, or other devices that do not have a significant
impact on the musculoskeletal functions of the body.
IV. POLICY
General Policy Statements
A.
It
is the policy of BWC to pay for approved artificial appliance purchases or
repairs:
1.
Out
of the surplus fund;
2.
When
the request for the artificial appliance purchase or repair meets the criteria
established in State, ex. Rel. Miller v. Industrial Commission, 71
Ohio St. 3d 229 (1994)(See Miller Policy); and
3.
When
the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of
that award.
B.
State
Fund Claim Requests
1.
MCOs
shall process state fund claim requests for artificial appliances.
2.
MCO-approved
artificial appliance requests shall be paid from the surplus fund if the
injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of
that award.
3.
MCOs
may utilize BWC’s self insured policy and procedure in developing artificial
appliance evaluation criteria.
4.
MCOs
may staff the following artificial appliance issues with BWC:
a.
Medical appropriateness
of requested artificial appliance;
b.
Medical examination
scheduling;
c.
Billing reimbursement
codes.
5.
MCOs
shall schedule medical examinations as set forth in paragraph IV.G.
6.
BWC
shall pay travel expenses associated with an artificial appliance in accordance
with the Travel Reimbursement Policy.
C. Self-Insured
Claim Requests
1.
BWC
shall process eligible self-insured claim requests for artificial appliances if
the injured worker has received an award under R.C. 4123.57(B) and the injured worker’s need for the artificial appliance arises out of that
award.
2.
BWC
shall reimburse prior authorized travel expenses associated with an artificial
appliance processed under IV.C.1 out of the surplus fund. See Travel
Reimbursement Policy.
3.
Artificial
appliance requests that BWC determines do not arise under the provisions of
R.C. 4123.57(B) shall not be processed by BWC and shall be returned to the
self-insured employer for processing.
D. Self-insured
employers requesting BWC processing of artificial appliance requests shall
submit all of the following to BWC:
1.
Written
evidence of payment to the injured worker of a scheduled loss or facial
disfigurement award under R.C. 4123.57(B) for the body part for which an
artificial appliance is being requested.
2.
Sufficient
medical and claim information for BWC to process a request for an artificial
appliance.
E.
BWC
shall ensure that the following information is available for processing an
artificial appliance request and may contact the provider(s) and/or prosthetist to obtain the information if necessary:
1.
Written
evidence that an artificial appliance has been determined to be medically
necessary for the injured worker from one of the following:
a.
The Ohio State
University hospital amputee clinic;
b.
The Rehabilitation
Services Commission;
c.
An amputee clinic
approved by the administrator or the administrator’s designee;
d.
A prescribing
physician approved by the administrator or the administrator’s designee.
2.
Dated
and signed prescription of the item being requested including the manufacturer,
brand name and model number;
3.
Recent
physical examination that includes a functional assessment with current and
expected ability, impact upon activities of daily living, assistive devices
utilized and co-morbidities that impact the use of the prescribed artificial
appliance;
4.
Clinical
rationale for requested artificial appliance, replacement part(s) or repair(s)
and a description of any labor involved;
5.
Coding
description for the artificial appliance or repair utilizing the healthcare
common procedure coding system (HCPCS). If a miscellaneous code is
requested, all component items bundled in the miscellaneous code shall be
listed along with a complete description and itemization of charges;
6.
Copy
of the manufacturer’s price list for items requested under a miscellaneous
HCPCS code; and
7.
Copy
of any warranties related to the requested artificial appliance.
F.
It
is the prosthetist’s responsibility to assure that
any prosthetic device fits properly for three months from the date of
dispensing. Any modifications, adjustments or replacements within the
three months are the responsibility of the prosthetist
who supplied the item and BWC will not reimburse for those services. The
provision of these services by another provider will not be separately
reimbursed.
G. Medical Examinations
1.
BWC
(for self-insuring employer requests) shall, and the MCO (for state fund
requests) may, schedule a multidisciplinary
examination (MDE) for prosthetics or an independent medical examination (IME)
for all other requests if:
a.
A
requested artificial appliance has not been available on the United States
market for at least two years; or
b.
In
all cases that a physician review recommends an MDE or IME.
2.
BWC
(for self-insuring employer requests) shall, and the MCO (for state fund
requests) may, schedule a MDE for the following prosthesis claim requests:
a.
All
initial multi-articulating hands or finger component prostheses;
b.
All
initial microprocessor knees and feet;
c.
Requests
for replacement knees and feet microprocessor components when any of the
following apply:
i. Microprocessor
components are still under warranty;
ii.
Documentation
evidences non-use of the prosthesis by the injured worker;
iii.
Documentation
evidences that replacement is inappropriate due to a change in medical
condition;
d.
All
initial custom silicone restorative passive devices;
e.
Requests
for replacement of custom silicone passive devices when either of the following
apply:
i. Documentation
evidences non-use of the prosthesis by the injured worker;
ii.
Documentation
establishes that replacement is inappropriate due to a change in medical
condition;
f.
Cases
with a history of five or more repairs and/or modifications of the prosthesis
within the past twelve months;
g. Cases involving
requests for authorization for specialized surgical intervention relating to
external/augmented prosthetic control (e.g., targeted muscle reinnervations), skeletal attachment (e.g., osteo-integration) or similar new or advanced technology.
3.
BWC
(for self-insuring employer requests) and the MCO (for state fund requests) may
schedule an MDE or an IME for individuals requesting an artificial appliance or
artificial appliance repair that are not subject to the provisions of IV.G.1. or IV.G.2., above.
BWC staff may
refer to the corresponding procedure for this policy entitled “Procedure for Artificial
Appliance Requests ” for further guidance.
Procedure
Name:
|
Procedures
for Artificial Appliance Requests
|
Procedure
#:
|
MP-16-01.PR1
|
Policy
# Reference:
|
MP-01-01
|
Effective
Date:
|
07/22/2013
|
Approved:
|
Freddie
Johnson, Chief of Medical Services (signature on file)
|
Supersedes:
|
All
policies and procedures regarding artificial appliance and self insured
prosthesis requests that predate the effective date of this procedure
|
History:
|
New
|
Review
date:
|
07/22/2018
|
I. BWC staff shall
refer to the Standard Claim File Documentation policy and procedure for
claim-note requirements and shall follow any other specific instructions
included in this procedure.
II. State Fund Claim
Requests
A. Managed Care Organizations (MCOs)
process state fund requests for artificial appliances, replacement part(s) or
repair thereof if the injured worker has received an award under R.C.
4123.57(B) and the injured worker’s need for the
artificial appliance arises out of that award, and may request BWC staffing of
the following issues relating to artificial appliance requests:
1. Medical appropriateness of requested
artificial appliance;
2. Medical examination scheduling;
3. Billing reimbursement codes.
B. MCOs shall direct staffing requests,
noting the injured worker’s (IW) name and claim
number, to:
1. BWC staff assigned to the claim; or
2. BWC catastrophic (CAT) nurse via email
to: BWC.catnurse@bwc.state.oh.us.
C. BWC staff shall respond to the staffing
request or forward it to the appropriate CAT nurse for response.
D. MCOs are responsible for processing
payment requests for MCO-approved artificial appliances in accordance with Medical
Billing and Adjustment Unit processing requirements.
E. MCOs shall forward travel reimbursement
requests to BWC for processing.
III. Self-Insured (SI) Claim Requests
A. Field staff reviewing a request for an
artificial appliance, replacement part or repair thereof, shall process the
request if the injured worker has received an award under R.C. 4123.57(B) and
the injured worker’s need for the artificial
appliance arises out of that award.
1. Field staff shall request additional
documentation from the employer if insufficient documentation has been received
to make a determination.
2. Field staff may consult with their local
BWC attorney for assistance if necessary in determining whether the injured worker’s need arises out of the award under R.C.
4123.57(B).
3. Field staff shall return the request to
the self insured employer for processing if the requirements of this paragraph
are not met and shall note in the claim file the decision rationale.
B. Once a decision is made to process the
request, field staff shall:
1. Send an email to the CAT nurse (BWC.catnurse@bwc.state.oh.us) with the IW’s
name and claim number. Field staff process the request and shall work
with the CAT nurse as noted.
2. Document that the following are met
prior to approving the artificial appliance, replacement part or repair:
a. The necessity for the artificial
appliance was identified in writing by one of the following:
i. The Ohio State
University hospital amputee clinic;
ii. The Rehabilitation Services
Commission;
iii. An amputee clinic approved by the
administrator or the administrator’s designee;
iv. A prescribing physician approved by the
administrator or the administrator’s designee.
b. The Miller criteria are
satisfied. (Refer to the Miller Policy). The following information will
assist in determining whether Miller criteria are satisfied:
i. From the
physician of record:
a) A detailed written order that is signed
and dated and includes:
i) The individual’s name and claim number;
ii) Narrative condition/description;
iii) Dated prescription;
iv)
Description of the item
being requested including the manufacturer, brand name, model number;
b) Medical documentation supporting the
necessity of the requested item reflecting:
i) Amputation history (if relevant),
therapeutic intervention, clinical course and treatment plan;
ii) Recent physical examination that
includes a functional assessment and impact upon activities of daily living (if
relevant), assistive devices utilized and co-morbidities that impact the use of
prescribed artificial appliance;
ii.
From
the prosthetist (if a prosthesis is requested):
a) Medical documentation supporting the
necessity of the requested item;
b) If relevant, dated and signed records
documenting current and expected functional ability with an explanation of any
difference. Lower limb prosthesis may utilize Medicare Functional
Classification Levels (K-levels) to express functional ability;
c) Dated and signed medical records
reflecting office visits and clinical rationale for the requested prosthesis, replacement
part(s) or repair(s) and description of any labor involved;
iii. A coding description for the artificial
appliance, replacement part(s) or repairs(s) utilizing the healthcare common
procedure coding system (HCPCS). If a miscellaneous code or by report
(BR) code is requested, all component items bundled in the miscellaneous or BR
code listed along with a complete description and itemization of charges;
iv. Manufacturer’s price list for items
requested under a miscellaneous or BR code;
v. Warranties related to the requested
artificial appliance.
3. If information set forth in III.B.2. is not in the provided medical records, field staff shall
contact the provider and/or prosthetist to obtain the
necessary information.
C. Artificial appliance requests meeting
the criteria set forth in paragraph III.B. may be
approved. Field staff shall complete the following when approving:
1. Staff the billing reimbursement codes
with the CAT nurse. If there are questions relating to requested codes or
pricing, the CAT nurse or field staff shall contact the provider to discuss the
requested codes or discrepancies between the usual and customary rate (UCR) and
the amount billed.
2. Update the claim management system with
the approval, including a notation of the specific allowed codes and allowed
miscellaneous or BR prices in the prior authorization screen with the allowed
date range (window).
3. Send an approval letter (C-47) to the
parties noting all allowed codes and the UCR or the allowed pricing for the
miscellaneous or BR codes.
a. Upon receipt of the C-19 Service Invoice
from the provider, field staff shall:
i. Compare the allowed codes and allowed
prices in the claim management system and the C-47 to the billed codes on the
C-19 Service Invoice to ensure a match.
ii. If the allowed codes and pricing
and the billed codes and pricing match, field staff shall approve the invoice.
iii. If there is a discrepancy between any of
the allowed codes and pricing and the billed codes and pricing on the C-19,
field staff shall additionally note in the “Remarks” block on the C-19, the
following:
a) Any code(s) that were not authorized in
the C-47 letter;
b) Any pricing discrepancies between the
C-19 and the C-47.
b. Compare the date of service on the C-19
(date of delivery of the service) to the allowed date range in the claim
management system. The service date must fall within the allowed date
range. If within the date range, field staff shall change the date range
in the claim management system to the date of service on the C-19. If the
date of service is out of the allowed date range, field staff shall contact the
CAT nurse.
c. Send the C-19 to Medical Billing and
Adjustments (MBA) so the bill can be paid via the surplus fund.
D. Field staff may consult with the CAT
nurse for assistance in reviewing an artificial appliance request.
Staffing will result in one of the following:
1. The request will be pended: field
staff shall send an additional request for documentation.
2. The request will be denied: field
staff shall update the claim management system and issue a denial letter (C-48)
to all parties.
3. The request will be referred for
physician file review or the injured worker will be scheduled for an
independent medical examination (IME) or a multidisciplinary evaluation
(MDE): field staff shall notify the injured worker in writing of the
scheduling of an IME or MDE.
a. If the physician file review or
multidisciplinary evaluation recommends denial of the request, field staff
shall deny the request, update the claim management system, generate a C-48 and
send it to all parties.
b. If the physician file review or
multidisciplinary evaluation recommends approval of the request, field staff
shall approve the request and follow the provisions set forth in paragraph
III.C.
E. The CAT nurse may contact the physician
and/or prosthetist to discuss recommended amendments
to the requested artificial appliance and/or repair request. Recommended
amendments may arise from the CAT nurse, physician review recommendations
and/or IME or MDE recommendations.
1. If amendments are recommended, the CAT
nurse shall request withdrawal of the original C-9 and request a revised C-9
reflecting the recommended amendments.
2. If a revised C-9 is submitted, the CAT
nurse will review it to ensure that recommended amendments were incorporated
and shall forward the request to field staff to complete the approval process
as set forth in III.C.2. and III.C.3.
3. If agreement cannot be reached with the
physician and/or prosthetist to withdraw and submit a
revised C-9, field staff shall deny the C-9 request, update the claim
management system and send a C-48 to all parties.
IV. BWC staff (for SI
employer requests) shall schedule Multidisciplinary Evaluations and/or
Independent Medical Examinations as follows:
A. The BWC CAT nurse shall schedule an:
1. MDE for prosthetics if:
a.
A
requested prosthetic has not been available on the United States market for at
least two years;
b. A physician review recommends an MDE; or
c. One of the following is requested:
i. All initial multi-articulating hands or
finger component prostheses;
ii. All initial microprocessor knees
and feet;
iii. Requests for replacement knees and feet
microprocessor components when any of the following apply:
a) Microprocessor components are still
under warranty;
b) Documentation evidences non-use of the
prosthesis by the injured worker;
c) Documentation evidences that replacement
is inappropriate due to a change in medical condition;
iv.
All initial custom silicone restorative passive devices;
v.
Requests for replacement of custom silicone passive devices when either of the
following apply:
a) Documentation evidences non-use of the
prosthesis by the injured worker;
b) Documentation establishes that
replacement is inappropriate due to a change in medical condition;
vi.
Cases with a history of five or more repairs and/or modifications of the
prosthesis within the past twelve months;
vii. Cases involving requests for
authorization for specialized surgical intervention relating to
external/augmented prosthetic control (e.g., targeted muscle reinnervations), skeletal attachment (e.g., osteo-integration) or similar new or advanced technology.
2. IME for any artificial appliance if:
a. A requested artificial appliance has not
been available on the United States market for at least two years; or
b. A physician review recommends an IME.
B. The BWC CAT nurse may schedule an MDE or
an IME for individuals requesting an artificial appliance or artificial
appliance repair that are not subject to the provisions of IV.A.
V. The
Multidisciplinary Evaluation
A. MDEs shall be scheduled at an amputee
clinic and, depending on the needs of the injured worker, shall be conducted by
a specialty physician, licensed physical or occupational therapist, and an
independent prosthetist, who
will consider and assess the injured worker’s current condition regarding the
amputation site and prosthetic needs. A prosthetist
is considered to be independent if he or she has not provided services to the
injured worker within the past two years.
B. The MDE shall include the following:
1. A physician report including:
a. Medical history;
b. History and physical;
c. Diagnostics that were reviewed;
d. Discussion of contributory medical
conditions that could be a barrier to use of the requested prosthetic device;
e. Discussion of current condition of the
amputation site and residual limb; and
f. Current functional status and
expected potential.
2. A physical or occupational therapist
report including:
a. Current functional status; and
b. Expected functional outcome.
3. A prosthetist
report including:
a. Prior prosthetic use, if applicable;
b. Current functional status;
c.
Expected
functional outcome;
d. HCPCS coding of the recommended device
or repair; and
e. Manufacturer list pricing of the
recommended device.
C. Staff shall provide relevant information
available in the claim file to the clinic performing the MDE, shall inform the
clinic of the information set forth in paragraph V.B. to be addressed through
the MDE and provide any additional questions to be addressed relevant to the
requested artificial appliance, replacement part(s) or repair(s).
D. The provider(s) performing the MDE shall
bill for services rendered in the MDE on a C-19 Service Invoice.
VI. Travel Reimbursement
A. Field staff (or the CAT nurse when
scheduling an MDE) shall process travel reimbursement requests as set forth in
the Travel Reimbursement Policy.
B. Field staff shall notify the IW of the
location of the travel reimbursement form (Form C-60) on ohiobwc.com and mail a
form to the IW if requested.