What WorkSafe will pay for

The WorkSafe Agent (the Agent) can pay the reasonable costs of external prostheses and orthoses where required as a result of a work-related injury or illness under Victorian workers compensation legislation (the legislation).

This policy must be read in conjunction with the Private Hospitals Policy.

This policy does not apply to surgically implanted prostheses. Refer to the surgically implanted prostheses policy.

Background 

External prostheses 

An external prosthesis is an artificial device that replaces a missing body part for functional and/or cosmetic reasons, including artificial limbs, facial features and digits. External prostheses can consist of components, such as feet and knee components, but do not include surgically implanted prostheses. 

External prostheses are sometimes provided in three stages: 

  • initial interim prostheses following amputation or residual limb revision, including trial components 
  • subsequent interim prostheses as the residual limb matures or due to a change in functional status 
  • definitive prostheses once the size and shape of the residual limb has stabilised. Different types of external prostheses can be prescribed depending on their purpose: 
  • general prostheses for everyday activity and function (including a back-up prosthesis for use when the everyday prosthesis is sent away for maintenance or repair) 
  • sporting or recreational prostheses for general sporting or recreational activities (can be provided in addition to a general prosthesis)  
  • elite sporting or recreational prosthesis (in exceptional circumstances for elite events or activities).
  • Osseo-integration for prostheses 
  • Osseo-integration is an elective surgical procedure that may be required as part of the worker's prosthetic management. 
  • Refer to the Elective Surgery Policy and Non-Established, New or Emerging Treatments and Services Policy. Orthoses An orthosis is a brace or splint used to support, align, prevent or correct musculoskeletal irregularities to improve function. 

Definitions 

In this policy: 

  • facial prosthesis replaces a lost facial feature, including the eyes, nose and ears. 
  • prosthetic digit replaces lost fingers and toes. 
  • condemned prosthesis means the prosthesis in no longer able to be used as it is clinically inappropriate or unsafe 
  • Consumables are items associated with the use of prostheses and orthoses that require regular replacement e.g. residual limb socks, plaster casts, sheaths. 
  • Minor repairs are any repairs to a prosthesis that cost less than $250 (including consumables, materials, consultation and manufacturing time). 
  • major repair is a repair of a prosthesis that costs over $250 that does not require a change of prescription. For example replacement of a socket, service of componentry, adjustment. 
  • Maintenance of a prosthesis means any service required to maintain the function of a prosthesis and adhere to warranty requirements. For example periodic servicing of microprocessor units. 

Guidelines 

 What can the Agent pay for in relation to external prostheses and orthoses? 

The Agent can pay the reasonable costs of external prostheses and orthoses:  

  • required as a result of a work-related injury or illness 
  • where safe and effective 
  • where the prosthesis or orthosis promotes functional independence, self-management or cosmetic improvement.

In relation to orthoses, the Agent can pay the reasonable costs of prescription, manufacture, supply and fitting of an orthosis. In relation to external prostheses, the Agent can pay the reasonable costs of: 

  • prescription, manufacture, supply and fitting of initial interim, subsequent interim, definitive and back up prostheses 
  • maintenance of a prosthesis for its serviceable life
  • modification or replacement of a prosthesis that becomes ill-fitting or is no longer serviceable when a change of prescription is provided 
  • repair, modification or replacement of a prosthesis required outside the manufacturer's warranty 
  • repair, adjustment or replacement of a pre-existing external prosthesis damaged as a result of a workrelated injury or illness 
  • specialised, higher-end prostheses and prosthetic componentry when supported by objective clinical evidence that the prescription will result in a demonstrated improved functional outcome for the worker 
  • prosthetic components that comply with ISO 10328 and the Therapeutic Goods (Medical Devices) Regulations 2002 (Cth). 

Prostheses for sporting or recreation activities 

The Agent can pay the reasonable costs of an entry level sporting or recreational prosthesis for: 

  • one sporting/recreational activity where the worker can demonstrate a willingness and/or capacity to commit to continued participation 
  • more than one form of sporting or recreational activity when the worker can demonstrate pre-injury or illness commitment to more than one sporting or recreational activity. 

Elite level sporting or recreational prostheses 

  • The Agent can pay the reasonable costs of an entry level sporting or recreational prosthesis as a contribution towards the total cost of an elite level prosthesis. The worker will be required to pay the difference between the entry level and elite level prosthesis. 

Who may provide prosthetic and orthotic services? 

Prosthetic services may be: 

  • prescribed, manufactured/supplied and fitted by a WorkSafe registered prosthetist, or 
  • prescribed by a registered medical practitioner who specialises in rehabilitation, in conjunction with a WorkSafe registered prosthetist. 

Facial prostheses or prosthetic digit services may be prescribed by a registered medical practitioner specialising in either facial prostheses or prosthetic digit services and may be manufactured/supplied and fitted by a suitably qualified health professional such as a dental prosthetist, maxillofacial prosthetist or technician. 

Orthotic services may be provided by: 

  • a WorkSafe registered orthotist , or 
  • a physiotherapist, podiatrist, chiropractor or osteopath, or 
  • an occupational therapist (only at the request of a medical practitioner). 

What information does the Agent require to consider paying for external prostheses and orthoses? 

Prostheses 

Prior written approval from the Agent is required for the provision of prostheses to a worker (with the exception of minor prosthetic repairs). 

Minor repairs 

Prior approval is not required for minor repairs to a prosthesis. 

Provision of new prostheses and maintenance, major repair, replacement or modification services for existing prostheses 

A Prosthetic Treatment Request Form must be submitted to the Agent and prior approval obtained before these services are provided. Clinical justification of the need for services due to the work related injury or illness, and details about current function, limitations, predicted outcomes and cost must be provided. 

Urgent major repairs 

For urgent major repairs, the information required in the Prosthetic Treatment Request Form may be provided verbally. The Agent may give a verbal approval for the repairs on the condition that the Prosthetic Treatment Request Form is completed and provided within 10 working days. 

Facial prostheses or prosthetic digits 

For facial prostheses and prosthetic digits, a copy of the specialist medical practitioner request is required in addition to the Prosthetic Treatment Request Form.

Prosthetic management 

 The Agent may request submission of a Prosthetics Management Review Lower Extremity Form or a Prosthetics Management Review Upper Extremity Form within three months of the final fitting of  prosthesis. 

Orthoses 

Prior approval from the Agent is required before orthoses that cost more than $250 are provided to a worker who is treated: 

  • at a private practice or 
  • as a hospital outpatient. 

For orthoses provided to an inpatient of a hospital, please refer to the relevant hospital policy. 

An Orthotic Device Request Form must be submitted to the Agent and prior approval obtained before these services are provided. Clinical justification of the need for services due to the work related injury or illness, and details about current function, limitations, predicted outcomes and cost must be provided. 

When will the Agent respond to a request? 

Within 10 working days of receiving a Prosthetic Treatment Request Form or Orthotic Device Request Form the Agent will advise whether: 

  • the request has been approved 
  • the request has been denied, or 
  • further information is required to make a decision. 

To assist the Agent to make a decision the request may be reviewed by the WorkSafe Clinical Panel. The Clinical Panel may contact the treating health practitioner to seek further information and/or discuss the proposed services prior to making a recommendation to the Agent. The Agent will respond to the request when they have received the Clinical Panel's recommendation. 

What are WorkSafe's invoicing requirements? 

  • Please refer to the How to invoice WorkSafe guidelines. 
  • Minor repairs can be invoiced directly to the Agent. 

What fees are payable for external prostheses and orthoses? 

Inpatient 

The Agent may not be able to pay for a prosthesis or orthosis where provided to a worker as a hospital inpatient. See the relevant hospital policy or check with the referring hospital 

Outpatient 

See the Department of Health Schedule of Fees and Charges for Acute Health Services in Victoria. Private practice For services and componentry provided in a private practice, refer to the Prosthetic and Orthotic Services Fee Schedule (for use by prosthetists and orthotists only). 

In determining the reasonable costs payable for a prosthesis the Agent will take into account: 

  • any significant changes in the residual limb shape and size, for example following surgical revision of the residual limb, or weight loss or gain. 
  • normal wear and tear 
  • the activity level of the worker and types of activities that the worker performs 
  • any anticipated changes in the worker's level of function and range of activities performed while using the prosthesis such as home, work duties or sport participation 
  • the componentry costs and whether the components can be reused in the replacement prosthesis, comply with ISO 10328 or equivalent and the Therapeutic Goods (Medical Devices) Regulations 2002 (Cth), and have current manufacturer warranties. 

In relation to external prostheses and orthoses, what won't the Agent pay for? 

The Agent will not pay for: 

  • repair or replacement of a prosthesis that the Agent did not pay for or was not damaged as a result of the work-related injury or illness  
  • maintenance, repair, modification or replacement of a prosthesis or orthosis under warranty 
  • a replacement prosthesis, where the original prosthesis remains serviceable and there is no prescription change 
  • repairs to a condemned prosthesis 
  • supply of a reused prosthesis 
  • services for a person other than the worker
  • services subcontracted to, or provided by a nonregistered provider 
  • services provided outside the Commonwealth of Australia without prior written approval from the Agent 
  • the cost of telephone calls and telephone consultations between providers and workers, and between other providers, including hospitals 
  • services where there is no National Health and Medical Research Council level 1 or 2 evidence that they are safe and effective. Refer to the NonEstablished, New or Emerging Treatments and Services Policy. 

Where the Agent has paid for a prosthesis the following conditions also apply: 

  • The prosthesis and its components must not be sold or traded, or disposed of without consultation with the treating prosthetist. 
  • No modifications, additions or alterations may be made to the prosthesis without consultation with the treating prosthetist. 
  • The Agent expects that reasonable care is taken to prevent damage, loss or theft of the prosthesis. 

Further information 

Contact the referring Agent or email [email protected].  

Note: This policy is a guideline issued by WorkSafe Victoria under Victorian workers compensation legislation in respect of the reasonable costs of services, and services for which approval should be sought from the WorkSafe Agent or self-insurer (as the case may be) before the services are provided.