T5001, Right foot, great toe
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation demonstrating the disease or medical condition places the member at increased risk of injury and/or makes them especially susceptible to harm from injury.
- For helmets: documentation of frequent, violent or uncontrolled seizures; or documentation of balance disorder; or documentation of head banging behaviors; or operative/clinical documentation of cranial surgery (to support coverage 'as a prosthetic of the skull when medically necessary after cranial surgery').
- For replacement helmet liner: documentation that the person previously qualified for coverage of a specialized helmet and that annual replacement of the liner is required.
- For bedside rails, safety enclosure frames, pediatric cribs, safety equipment, restraints and vehicular restraint systems: documentation of neurocognitive or physical disabilities that place the person at increased risk for falling from the bed or at increased risk of injury, and a physician order prescribing the specific safety device and medical rationale.
Key Coverage Criteria
- Annual replacement of the replacement liner is considered medically necessary and covered for persons who qualify for coverage of a specialized helmet.
- For non-standard plans that do not exclude coverage of safety items, Aetna covers safety items for members with diseases or medical conditions that: place them at increased risk of injury; and/or make them especially susceptible to harm from injury.
- Continuously worn prefabricated or custom-made soft or hard specialized medical protective helmets are considered medically necessary to prevent injury due to frequent, violent or uncontrolled seizures, balance disorders, head banging behaviors, or following cranial surgery.
- A specialized helmet may be covered as a prosthetic of the skull when medically necessary after cranial surgery (explicit cross-reference: CPB 0379 - Cranial Remodeling and CPB 0543 - Hospital Beds and Accessories for related coverage of bed enclosure frames when part of a medically necessary hospital bed).
- Under non-standard plans that do not exclude safety items, grab bars that are affixed to a wall or floor, such as around the bathtub or toilet, are [not covered under the standard exclusion for addition or alternations to a home, workplace or other environment] (i.e., may be covered under such non-standard plans).
- Under non-standard plans that do not exclude safety items, hospital bedside rails, hospital bed safety enclosure frames, and enclosed hospital-grade pediatric cribs would be considered medically necessary for persons with neurocognitive or physical disabilities that place them at increased risk for falling from the bed.
2 Active Policies
AETNA-CPB-0623, Safety Items
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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