Update to Multiple Prosthetics Coverage

Friday, February 25, 2022

Prosthetics, also known as prosthesis and related supplies, are covered under TRICARE when medically necessary. Prior policy specified that only one prosthetic may be covered at a time unless the beneficiary required bilateral prosthetics. Recent updates to the TRICARE Policy Manual (Chapter 8, Section 4.1) clarify that while in most cases only one permanent prosthetic at a time is medically necessary, additional prosthetics may be covered if they serve a different purpose, or have essential functional differences, even if used for the same limb. In such cases, these would not be considered duplicate equipment and may be authorized. Be sure to include supporting documentation with all prior authorization requests, as this will expedite our review. 

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. 

As a reminder:

• Replacement prosthetics may be covered:
  • 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.

(Be sure to clearly indicate in your authorization request the reason for the replacement.) 

• TRICARE excludes prosthetics for sports-related purposes, exercise equipment or physiotherapy.
  
  
• Active duty service members with major limb amputations may be eligible for multiple prostheses under the Supplemental Health Care Plan.

Visit our Prosthetics Benefits A-Z page to learn more about coverage and prior authorization requirements.