Prosthetics

Prosthetics, also known as prosthesis and related supplies, are a covered benefit when medically necessary. Prior authorization is required.

Multiple prosthetics may be covered:

If a beneficiary requires bilateral prosthetics.
If the additional prosthetic serves a different purpose, or has essential functional differences, even if used for the same limb. In such cases, these would not be considered duplicate equipment and may be authorized. An example of non-duplicative prosthetic is a foreshortened prosthetic (sometimes called “stubbies”) for use when a fully articulating bilateral leg prosthetic is not appropriate.

Services to train the beneficiary on the device, repair for normal wear and tear or damage, and customization of the device are a covered benefit.

A replacement prosthetic is covered when needed:

due to growth; or
a change in the beneficiary’s condition; or
an item is lost, irreparably damaged or the cost of repair would exceed 60 percent of the cost of replacement.

Prosthetics for sports related purposes (if an initial prosthetic was already cost-shared), exercise equipment or physiotherapy are not covered benefits.

Active duty service members with major limb amputations may be eligible for multiple prostheses under the Supplemental Health Care Plan.

All ADSMs who have sustained an amputation(s) must first get an initial assessment (in person or telephonically) at one of the following Advanced Rehabilitation Center (ARC) locations, as arranged by the ADSM’s military hospital or clinic:
- The Center for the Intrepid, San Antonio Military Medical Center, San Antonio, Texas;
- Walter Reed National Military Medical Center, Bethesda, Maryland; or
- The Comprehensive Combat and Complex Casualty Care, Naval Medical Center, San Diego, California.
If the ARC is unable to accommodate the ADSM, ARC staff will work with the ADSM’s military hospital providers and regional contractor (HNFS in the West Region) to coordinate care by civilian network providers.