1.04.01ARCHIVADA PROTÉSIS E IMPLANTES
SecciónEquipo Médico Duradero Fecha Original: 02/14/1997
SubsecciónAparatos Prostéticos Fecha Revisión21 de noviembre de 2016
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Definición


El implante es un objeto, material o artefacto que se coloca dentro del cuerpo.
Una prótesis es un reemplazo artificial para una parte disfuncional del cuerpo, que se fabrica y se adapta a las medidas y necesidades individuales de la persona y provee funcionalidad y/o movilidad. La prótesis se fabrica a la medida del individuo que va a ser su recipiente. La prótesis sustituye un órgano del cuerpo que no funciona o está ausente.
Los artefactos que se utilizan en la cirugía espinal se consideran implantes, así los denominan las compañías que los manufacturan. Los implantes espinales se utilizan para darle estabilidad temporal y mantener alineamiento de la columna, en lo que ocurre la fusión. Muchos fabricantes de estos dispositivos los denominan herrajería o “hardware”. Una vez ocurre la fusión el implante o placa se queda internamente y de rutina no son removidos.
Política
I. Prótesis e implantes quirúrgicos que se consideran para pago:
A. Prótesis
  • Articulaciones artificiales para reparar la articulación o reconstruirla

  • Lentes intraoculares

  • Prótesis de mama (incluyendo el sostén)

  • Marcapasos cardiaco, atómicos o electrónicos

  • Aparatos maxilofaciales que reemplacen parte de la oreja o la nariz

  • Prótesis de Pene, cuando la impotencia resulta como producto de trauma o enfermedad

  • B. Implantes
  • Implantes Cocleares

  • Deflux, Hyalgan y Synvisc

  • Dispositivos para reemplazar el esfínter de la uretra en casos de incontinencia urinaria.

  • Placas, tornillos, clavos, (herrajería) para cirugías espinales, o musculoesqueletal.

  • Válvulas cardiacas, Stent

  • II. Prótesis no quirúrgicas que se consideran para pago:
  • Ojos Artificiales

  • Extremidades Artificiales o parte de ellas

  • Dispositivos que faciliten el habla

  • Sistema de almacenar orina en casos de incontinencia urinaria permanente

  • Sistema de colección y retención en casos de colostomía

  • La cubierta incluye los suplidos necesarios para el uso efectivo de los aparatos prostéticos cubiertos Ej. Baterías necesarias para operar una laringe artificial, medias y zapatos cuando estos son parte integral de una pierna artificial.
    Ajuste y reparaciones de los dispositivos serán cubiertos cuando son necesarios para que el equipo funcione adecuadamente.
    Los reemplazos serán necesarios solamente cuando el uso los haya convertido en inefectivos.
    No se considera para pago bajo cubierta MQ o MM:
  • Dispositivos eléctricos para tratar incontinencia anal o urinaria

  • Pelucas

  • Dispositivos para audición

  • Implantes para efectos cosméticos

  • Prótesis de Pene por disfunción psicogénica

  • Códigos
    Según negociación con Departamento de Facilidades y Servicios Profesionales o la Coordinadora del Programa de Manejo Individual
    Codes Number Description
    CPT Code applicable prosthetic
    ICD-9 Procedure Code appropriate “Insertion” codes
    ICD-9 Diagnosis Code appropriate condition
    HCPCS L5000–L9999 Prosthetics code range
    ICD-10-CM(effective 10/1/15) Code appropriate condition
    ICD-10-PCS(effective 10/1/15) Not applicable. ICD-10-PCS codes are only used for inpatient services. The codes below are for insertion, replacement or supplement procedures that might include prosthetic devices.
    09HD0S2, 09HD0S3, 09HE0S2, 09HE0S3 Surgical, ear, nose & sinus, insertion, hearing device, cochlear prosthesis, code by body part (right or left) and qualifier (single channel or multiple channel)
    08RJ3KZ, 08RK3KZ Surgical, eye, replacement, lens, nonautologous tissue, code by body part (right or left)
    08R00JZ, 08R00KZ, 08R03JZ, 08R03KZ, 08R10JZ, 08R10KZ, 08R13JZ, 08R13KZ Surgical, eye, replacement, eye, code by body part (right or left), approach (open or percutaneous) and device (synthetic substitute or nonautologous tissue)
    0HRT0JZ, 0HRT0KZ, 0HRU0JZ, 0HRU0KZ, 0HRV0JZ, 0HRV0KZ Surgical, breast, replacement, open, code by body part (right, left or bilateral), and device (synthetic substitute or nonautologous tissue)
    0VUS0JZ, 0VUS0KZ, 0VUS4JZ, 0VUS4KZ Surgical, male reproductive system, supplement, penis, code by approach (open or percutaneous endoscopic) and device (synthetic substitute or nonautologous tissue)
    0THD0LZ, 0THD3LZ, 0THD4LZ, 0THD7LZ, 0THD8LZ, 0THDXLZ Surgical, urinary system, insertion, urethral sphincter, code by approach (open, percutaneous, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic, or external)
    0RRC0JZ,,0RRC0KZ, 0RRD0JZ, 0RRD0KZ Surgical, upper joints, replacement, temporomandibular joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRE0JZ, 0RRE0KZ, 0RRF0JZ, 0RRF0KZ Surgical, upper joints, replacement, sternoclavicular joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRG0JZ, 0RRG0KZ, 0RRH0JZ, 0RRH0KZ Surgical, upper joints, replacement, acromioclavicular joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRJ0JZ, 0RRJ0KZ, 0RRK0JZ, 0RRK0KZ Surgical, upper joints, replacement, shoulder joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRL0JZ, 0RRL0KZ, 0RRM0JZ, 0RRM0KZ Surgical, upper joints, replacement, elbow joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRN0JZ, 0RRN0KZ, 0RRP0JZ, 0RRP0KZ Surgical, upper joints, replacement, wrist joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRQ0JZ, 0RRQ0KZ, 0RRR0JZ, 0RRR0KZ Surgical, upper joints, replacement, carpal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRS0JZ, 0RRS0KZ, 0RRT0JZ, 0RRT0KZ Surgical, upper joints, replacement, metacarpocarpal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRU0JZ, 0RRU0KZ, 0RRV0JZ, 0RRV0KZ Surgical, upper joints, replacement, metacarpophalangeal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0RRW0JZ, 0RRW0KZ, 0RRX0JZ, 0RRX0KZ Surgical, upper joints, replacement, finger, phalangeal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRC0JZ, 0SRC0KZ, 0SRD0JZ, 0SRD0KZ Surgical, lower joints, replacement, knee joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRF0JZ, 0SRF0KZ, 0SRG0JZ, 0SRG0KZ Surgical, lower joints, replacement, ankle joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRH0JZ, 0SRH0KZ, 0SRJ0JZ, 0SRJ0KZ Surgical, lower joints, replacement, tarsal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRK0JZ, 0SRK0KZ, 0SRL0JZ, 0SRL0KZ Surgical, lower joints, replacement, metatarsal-tarsal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRM0JZ, 0SRM0KZ, 0SRN0JZ, 0SRN0KZ Surgical, lower joints, replacement, metatarsal-phalangeal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRP0JZ, 0SRP0KZ, 0SRQ0JZ, 0SRQ0KZ Surgical, lower joints, replacement, toe phalangeal joint, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRT0JZ, 0SRT0KZ, 0SRU0JZ, 0SRU0KZ Surgical, lower joints, replacement, knee joint, femoral surface, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SRV0JZ, 0SRV0KZ, 0SRW0JZ, 0SRW0KZ Surgical, lower joints, replacement, knee joint, tibial surface, open, code by body part (right or left) and device (synthetic substitute or nonautologous tissue)
    0SR90KZ, 0SR90J5, 0SR90J6, 0SR90J7, 0SR90J8, 0SR90JZ, 0SRB0KZ, 0SRB0J5, 0SRB0J6, 0SRB0J7, 0SRB0J8, 0SRB0JZ Surgical, lower joints, replacement, hip joint, open, code by body part (right or left), device (synthetic substitute or nonautologous tissue), and qualifier for the synthetic substitute (metal on polyethylene, metal on metal, ceramic on ceramic, ceramic on polyethylene, no qualifier)
    0SRA0KZ, 0SRA0JF, 0SRA0JG, 0SRA0JH, 0SRA0JZ, 0SRE0KZ, 0SRE0JF, 0SRE0JG, 0SRE0JH, 0SRE0JZ Surgical, lower joints, replacement, hip joint, acetabular surface, open, code by body part (right or left), device (synthetic substitute or nonautologous tissue), and qualifier for the synthetic substitute (metal, ceramic, polyethylene, no qualifier)
    0SRR0KZ, 0SRR0JF, 0SRR0JG, 0SRR0JZ, 0SRS0KZ, 0SRS0JF, 0SRS0JG, 0SRS0JZ Surgical, lower joints, replacement, hip joint, femoral surface, open, code by body part (right or left), device (synthetic substitute or nonautologous tissue), and qualifier for the synthetic substitute (metal, ceramic, polyethylene, no qualifie

    Limitación
    Toda prótesis o implante dental está incluida en la cubierta dental, de estar incluido tal beneficio.
    Los pañales y las sábanas de goma no están cubiertos bajo esta definición.
    Los aparatos prostéticos e implantes serán cubiertos a través de la cubierta de gastos médicos mayores por pago y reembolso.
    Los suplidos y reemplazos de los aparatos se cubrirán en aquellas cubiertas que así lo especifiquen.
    La asignación de beneficios aplica para aquellas prótesis e implantes con un costo mayor de $500.00, aplicando los copagos y deducibles establecidos en la cubierta.
    Se requiere una autorización previa para estos servicios y está sujeta a sus reglas y limitaciones.
    ___________ ____________________________
    Ángela T. Hernández, MD Benjamín Santiago, MD
    Director Médico Asociado Director Médico Ejecutivo
    Rev.11/21/2016
    04/28/2015
    01/17/2012 (ICD-10 and Reference added)
    01/26/09 (iCES)
    08/16/07
    03/07/07
    01/26/05
    02/14/97

    Referencias

  • American College of Radiology: Appropriateness Criteria. http://www.acr.org/Quality-Safety/Appropriateness-Criteria/Diagnostic/Musculoskeletal-Imaging (Accessed on May 31, 2012

  • Phillips AC, Polisson RP. The rational initial clinical evaluation of the patient with musculoskeletal complaints. Am J Med 1997; 103:7S.

  • Palestro CJ, Swyer AJ, Kim CK, Goldsmith SJ. Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging. Radiology 1991; 179:645.

  • Roth TD, Maertz , Parr JA, et al. CT of the hip prosthesis: appearance of components, fixation, and complications. Radiographics 2012; 32:1089

  • Shellock FG, Morisoli S, Kanal E. MR procedures and biomedical implants, materials, and devices: 1993 update. Radiology 1993; 189:587.

  • The diagnosis of periprosthetic joint infections of the hip and knee. Guidelines and evidence report. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, June 18, 2010

  • Gillespie WJ. Prevention and management of infection after total joint replacement. Clin Infect Dis 1997; 25:1310.