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317:30-5-211.13.Prosthetic devices
[Revised 12-03-09]
Coverage of prosthetics for adults is limited to (1) home dialysis equipment and supplies, (2) nerve stimulators, (3) external breast prosthesis and support accessories, and (4) implantable devices inserted during the course of a surgical procedure. Prosthetics prescribed by an appropriate medical provider and as specified in this section are covered items for adults. There is no coverage of orthotics for adults.
(1) Home dialysis. Equipment and supplies are covered items for members receiving home dialysis treatments only.
(2) Nerve stimulators. Payment is made for transcutaneous nerve stimulators, implanted peripheral nerve stimulators, and neuromuscular stimulators.
(3) Breast prosthesis, bras, and prosthetic garments.
(A)Payment is limited to:
(i) one prosthetic garment with mastectomy form every 12 months for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis;
(ii) two mastectomy bras per year; and
(iii) one silicone or equal breast prosthetic per side every 24 months; or
(iv) one foam prosthetic per side every six months.
(B) Payment will not be made for both a silicone and a foam prosthetic in the same 12 month period.
(C) Breast prostheses, bras, and prosthetic garments must be purchased from a Board Certified Mastectomy Fitter.
(D) A breast prosthesis can be replaced if:
(i) lost;
(ii) irreparably damaged (other than ordinary wear and tear); or
(iii) the member's medical condition necessitates a different type of item and the physician provides a new prescription explaining the need for a different type of prosthesis.
(E) External breast prostheses are not covered after breast reconstruction is performed except in instances where a woman with breast cancer receives reconstructive surgery following a mastectomy, but the breast implant fails or ruptures and circumstances are such that an implant replacement is not recommended by the surgeon and/or desired by the member.
(4) Prosthetic devices inserted during surgery. Separate payment is made for prosthetic devices inserted during the course of surgery when the prosthetic devices are not integral to the procedure and are not included in the reimbursement for the procedure itself.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.