Orthotic and Prosthetic Devices

Orthotic and Prosthetic devices are purchased for customers when prescribed by the treating physician, physician’s assistant or nurse practitioner, and medical necessity is documented. An item is medically necessary if it is needed to maintain or improve a beneficiary’s medical, physical or functional level. Orthotic and prosthetic devices purchased by Medicaid become the property of the Medicaid beneficiary.

Fee Schedules

Clinical Coverage Policy 5B, Orthotics and Prosthetics

Prior Approval Forms

Prior Approval Form for Lower Extremity Prosthetic Component L5781 and L5782

Prior Approval Form for Lower Extremity Prosthetic Component L5930

Prior Approval Form for Lower Extremity Prosthetic Component L5968

Prior Approval Form for Lower Extremity Prosthetic Component L5980

Prior Approval Form for Lower Extremity Prosthetic Component L5987

Prior Approval Form for Lower Extremity Prosthetic Component L5988

Request for Prior Approval CMN/PA

Request for Prior Approval CMN/PA - Continuation Form

Contact

Medical Assistance Clinical Section
Phone: 919-855-4310
Fax: 919-715-9451
Email: frake.hunsel@dhhs.nc.gov

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