Transcription of Prosthetic Devices, Wigs, Specialized, Microprocessor or ...
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Prosthetic Devices, Wigs, Specialized, Microprocessor or ...
Prosthetic devices , wigs , specialized , Microprocessor or Myoelectric Limbs Page 1 of 21 UnitedHealthcare Commercial Coverage Determination Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Commercial Cover a ge Deter mina tion Guideline Prosthetic devices , wigs , specialized , Microprocessor or Myoelectric Limbs Guideline Number: Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Documentation Requirements .. 5 Definitions .. 6 Applicable Codes .. 7 References .. 20 Guideline History/Revision Information .. 20 Instructions for Use .. 20 Coverage Rationale Indications for Coverage Implantable devices /prostheses, such as artificial heart valves, are not prosthetics.
o Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits include mastectomy bras. Benefits for lymphedema stockings for the arm are provided as described under the Coverage Determination Guideline titled Durable Medical Equipment (DME), Orthotics, Medical Supplies, and Repairs/Replacements.
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