CG-OR-PR-10 Osseointegrated Limb Prostheses

This policy addresses osseointegrated limb prostheses (bone-anchored prosthetic attachments) for individuals with transfemoral, transtibial, transhumeral, or forearm amputations. Coverage is medically necessary only when all criteria in sections A and B are met, including being skeletally mature with normal skeletal anatomy, age 18–70, and without diabetes, peripheral vascular disease, or metabolic bone disease (e.g., osteoporosis with T-score ≤ -2.5). The service is not medically necessary when these criteria are not met or for any other indications.

"Osseointegrated limb prostheses are consideredmedically necessaryfor individuals with transfemoral, transtibial, transhumeral, or forearm amputations whenallof the criteria set forth in (A) and (B)..."

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