Meeting the basic coverage (eligibility) criteria of insurance policies for certain prosthetic and orthotic devices/codes and establishing unmet patient needs is essential for successful claim reviews and reimbursement decisions. This course will discuss the thought process of claim reviewers and medical directors of insurance companies for assessing the medical necessity of interventions. You will hear about how to document the basic coverage (eligibility) criteria and how to establish unmet patient needs to justify prosthetic or orthotic technology upgrades. The course will also discuss how existing published evidence can be used to support your clinical judgment for component selection.

Learning Objectives

1. Describe how claim reviewers and medical directors of insurance companies define medical necessity.
2. Describe what criteria claim reviewers and medical directors use to review a prosthetic or orthotic claim.
3. Document that a patient meets basic coverage (eligibility) criteria of an insurance policy.
4. Document unmet patient needs that justify a technology upgrade.
5. Use published evidence to support their clinical judgment for component selection.