Harvard Pilgrim has developed new Medical Review Criteria—which will take effect on October 1, 2013—for electric, myoelectric, and/or microprocessor-controlled upper and lower limb prostheses. Harvard Pilgrim will continue to cover prosthetic limbs that are medically necessary to perform ordinary activities of daily living, and to provide Advance Coverage Determinations for all prosthetic devices upon request. The new criteria were established to improve this process and help ensure timely, consistent coverage determinations for these advanced devices.
When a multidisciplinary assessment (including an evaluation by a trained prosthetic clinician or other appropriate healthcare professional) documents that specific criteria are met, Harvard Pilgrim will provide a determination of coverage for microprocessor-controlled leg prostheses that are medically necessary for active individuals with knee disarticulation or trans-femoral amputations and electric or myoelectric upper limb prostheses that are medically necessary for members with amputation/absence of upper limb.
Harvard Pilgrim will cover replacement of prosthetic devices and components needed due to a change in the member’s physical or medical condition, or in the case of irreparable wear provided the cost of the repairs is expected to exceed 60% of the cost of replacement. However, Harvard Pilgrim will not cover repair or replacement resulting from negligence or improper use.
For more information, please refer to the Lower Limb Prostheses and Upper Limb Prosthetics Medical Review Criteria.