Page 138 - Medicare Benefit Policy Manual

Final determination established on 09-26-22.

120 - Prosthetic Devices

(Rev. 1, 10-01-03)
B3-2130, A3-3110.4, HO-228.4, A3-3111, HO-229

A. General

Prosthetic devices (other than dental) which replace all or part of an internal body organ
(including contiguous tissue), or replace all or part of the function of a permanently
inoperative or malfunctioning internal body organ are covered when furnished on a
physician’s order. This does not require a determination that there is no possibility that
the patient’s condition may improve sometime in the future. If the medical record,
including the judgment of the attending physician, indicates the condition is of long and
indefinite duration, the test of permanence is considered met. (Such a device may also be
covered under §60.l as a supply when furnished incident to a physician’s service.)

Examples of prosthetic devices include artificial limbs, parenteral and enteral (PEN)
nutrition, cardiac pacemakers, prosthetic lenses (see subsection B), breast prostheses
(including a surgical brassiere) for postmastectomy patients, maxillofacial devices, and
devices which replace all or part of the ear or nose. A urinary collection and retention
system with or without a tube is a prosthetic device replacing bladder function in case of
permanent urinary incontinence. The foley catheter is also considered a prosthetic device
when ordered for a patient with permanent urinary incontinence. However, chucks,
diapers, rubber sheets, etc., are supplies that are not covered under this provision.
Although hemodialysis equipment is a prosthetic device, payment for the rental or
purchase of such equipment in the home is made only for use under the provisions for
payment applicable to durable medical equipment.

An exception is that if payment cannot be made on an inpatient’s behalf under Part A,
hemodialysis equipment, supplies, and services required by such patient could be covered
under Part B as a prosthetic device, which replaces the function of a kidney. See the
Medicare Benefit Policy Manual, Chapter 11, “End Stage Renal Disease,” for payment
for hemodialysis equipment used in the home. See the Medicare Benefit Policy Manual,
Chapter 1, “Inpatient Hospital Services,” §10, for additional instructions on
hospitalization for renal dialysis.

NOTE: Medicare does not cover a prosthetic device dispensed to a patient prior to the
time at which the patient undergoes the procedure that makes necessary the use of the
device. For example, the A/B MAC (B) does not make a separate Part B payment for an
intraocular lens (IOL) or pacemaker that a physician, during an office visit prior to the
actual surgery, dispenses to the patient for his or her use. Dispensing a prosthetic device
in this manner raises health and safety issues. Moreover, the need for the device cannot