Alberta Aids to Daily Living Manual P - Prosthetic Benefits … · 2017-11-02 · Pricing effective April 1, 2015 ... Catalogue Number Information General Information Use the AADL

Alberta Health

AADL Approved Product List - Prosthetic Benefits

Pricing effective April 1, 2015

© 2013 Government of Alberta April 1, 2014

Generic Pricing Procedure

Catalogue Number Information

General Information

Use the AADL Generic Calculator to determine the AADL price for a generic catalogue number.

Procedure 1. Locate the catalogue number and enter the manufacturer invoice cost for the component into the calculator. Do not include shipping costs, exchange or any other cost. The cost used for generic catalogue number must be the manufacturer's invoice cost only. The calculator will automatically add mark-up, shipping and labour costs.2. Copy and paste the calculation into the Benefit Note on E-Business. Be sure to also indication the manufacturer and model number in the Benefit Note.3. Costs over the indicated maxmimum are indicated in the calculator and are considered an upgrade.

The AADL funding amount (AADL Price) for most orthotic and prosthetic benefit catalogue numbers is determined using the following formula:

(Material Cost + Markup) + (Shipping Cost) + (Labour Hours x Charge-Out Rate)

Definitions:

Material CostThe estimated, reasonable costs for the materials required to provide benefit. Where possible the cost will be based on the manufacturer's price list. Note: for Generic Catalogue Numbers the Specialty Supplier's actual invoice cost is used.

MarkupAn aditional amount added to the AADL Price intended to account for handling, rework and loss. For most benefits this is determined by taking a percentage of the Material Cost.

Shipping CostThe estimated, reasonable cost to ship the materials from the manufacturer to the Specialty Supplier.

Labour HoursThe estimated, reasonable number of hours required for a Certified Orthotist/Prosthetist and Technician to assess/fabricate/provide the the benefit.

Charge-Out RateAn hourly rate to account for the Specialty Supplier's costs related to providing the benefit. This includes the estimated, reasonable costs for: most overhead expenses (excluding materials and shipping cost); labour costs for certified and technical staff; administrative costs and profit margin.

Note: The above formula and definitions are provided for information purposes only. AADL reserves the right to set and adjust funding amounts as it deems appropriate.


Page 2 of 35

Alberta Health - Professional Services and Health Benefits Alberta Aids to Daily Living Manual P - Prosthetics Approved Product List

© 2015 Government of Alberta Revised April 1, 2015

APL P-1

Functional Levels

General Information

Lower Limb

Level 0 Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.

Level 1 The ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed pace. This prosthesis is typical for the household ambulator.

Level 2 The ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. This prosthesis is typical for the limited community ambulator.

Level 3 The ability or potential for ambulation with variable pace. This prosthesis is typical of a community ambulator with the ability to traverse most environmental barriers while participating in activities of daily living that require prosthetic use beyond simple locomotion.

Level 4 The ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. This prosthesis is typical of the prosthetic demands of the child or active adult functioning in the community.

Upper Limb

Level 5 The ability to enhance a patient's body awareness to improve quality of life and or prepare for the patient's future functional ability.

Level 6 The ability to use the prostheses for basic hand skill activities. Generally, these activities are required for lifting, stabilizing or holding objects between two extremities.

Level 7 The ability to demonstrate a high level of function with the prosthesis that enables a client to perform sophisticated, hand skill patterns. Some typical activities would include grasping and releasing, positioning (pre-position) of the terminal device, or changing to alternate terminal devices.

Level 9 The ability to demonstrate a high level of function with a myoelectric prosthesis that enables a client to perform sophisticated, hand skill patterns.


Page 3 of 35



APL P-2

Alberta Health - Professional Services and Health BenefitsAlberta Aids to Daily Living - Manual P - Approved Product List - Prosthetic Benefits

###Lower Limb Prosthetic Benefits

Functional

LevelCat. No. AADL PriceQty. / Freq.

(#hrs/material/ship)

#Stump Protectors

Physician Prescription Required

Stump Protector 1 Protector Per Limb Per 2 Years

False

For immediate post-operative use. A socket adaptor may be added in order to determine the client's eligibilty/suitabilty for a definitive prosthesis.

P9261 - 7, or 9 $838.35 Each(4/116/0)

##Shrinker Socks - Lower Limb

Shrinker Socks - Custom Made 6 Socks Per 12 Months

FalseP5411 - 4 Prior Approval

TF Shrinker Sock - After 12 Months 2 Socks Per 12 Months

FalseP5791 - 4 $63.87 Each(0.05/46/2)

TF Shrinker Sock - New Amp 3 Socks Per 12 Months

FalseP5201 - 42HPM9613 $63.87 Each(0.05/46/2)

TT Shrinker Sock - Non-Ambulatory 2 Socks Per 12 Months

FalseP5810 $52.39 Each(0.05/36/2)

TT Shrinker Sock - After 12 months 3 Socks Per 12 Months

FalseP5821 - 4 $52.39 Each(0.05/36/2)

TT Shrinker Sock - New Amp 6 SocksSocks Per 12 Months

FalseP4901 - 42HPHDW $52.39 Each(0.05/36/2)

##Lower Limb Socket Procedures


Check Socket 2 Check Socket Per 2 Years

FalseP1131 - 4Ankle Disarticulation/Chopart P-SK-301 $807.21 Each(3.75/111/18)

FalseP1201 - 4Hemipelvectomy $939.96 Each(4.5/111/18)

FalseP1191 - 4Hip Disarticulation P-SK-306 $939.96 Each(4.5/111/18)

FalseP1161 - 4Knee Disarticulation P-SK-303 $807.21 Each(3.75/111/18)

FalseP4981 - 4Proximal Femoral Focal Deficiency PFFD $797.88 Each(3.75/104/16)

FalseP1171 - 4Transfemoral P-SK-304 $807.21 Each(3.75/111/18)

FalseP1141 - 4Transtibial P-SK-302 $753.63 Each(3.5/104/16)

Definitive Socket 1 Procedure Per 2 Years

FalseP0121 - 4Ankle disarticulation (AD) P-AD-20 $3,348.30 Each(18/122/24)


Page 4 of 35



APL P-3



Functional



##Lower Limb Socket Procedures



FalseP9291 - 4Boyde/Chopart $3,569.55 Each(19.25/122/24)

FalseP0331 - 4Hip Disarticulation/Hemipelvectomy (HD/HP) HD-70 $4,928.39 Each(25.75/277/60)

FalseP0201 - 4Knee Disarticulation (KD) $4,174.88 Each(22.25/176/38)

False

Prior Approval - Fax the name of the client, PHN, description of the procedure, cost of materials and hours to fabricate the partial foot prosthesis. When approved by the AADL Manager, create the authorization on E-Business.

P0031 - 4Partial Foot Prior Approval

FalseP0311 - 4Proximal Femoral Focal Deficiency (PFFD) PD-60 $5,288.53 Each(28.5/182/39)

FalseP9281 - 4Rotation Plasty $3,932.73 Each(21.5/101/13)

FalseP0271 - 4Transfemoral (TF) P-TF-50 $4,359.28 Each(23.25/182/39)

FalseP0171 - 4Transtibial (TT) P-TT-30 $3,534.47 Each(19.25/94/20)

Socket Replacement - New Amputee 1 Early Replacement Per 2 Years

False

Replacement within 6 months

P0961 - 4Above Knee P-TF-51 $4,359.28 Each(23.25/182/39)

False


P0991 - 4Below Knee Socket P-TT-31 $3,534.47 Each(19.25/94/20)

False


P0951 - 4Knee Disarticulation Socket $4,174.88 Each(22.25/176/38)

Temporary Socket 3 Temporary Sockets Per 2 Years

False

For new amputee or client with complex issues with volume and/or shape.Criteria: Where multiple sockets will be required due to anticipated swelling and/or shape and/or volume change of the stump. If a check socket is required, only 2 temporary sockets will be funded. Ambulation with socket.

E7031 - 7, or 9 $1,295.63 Each(6.5/111/20)

##Additions to Lower/Upper Limb Procedures

Air Cushion - Transfemoral 1 Per 2 Years

FalseP1411 - 4 $544.97 Each(2.5/78/14)

Bariatric Option 1 Per 2 Years

False

Client is 100 lb. over normal weight or over 275 lb.

P9241 - 4 $466.00 Each(2/100/0)


Page 5 of 35



APL P-4



Functional




ISNY Socket Modifications 1 Per 2 Years

FalseP9311 - 7, or 9 $177.00 Each(1/0/0)

Suction Socket Procedure 1 Suction Socket Per 2 Years

False

To be billed with definitive prosthesis only

P1631 - 7 $177.01 Each(1/0/0)

Suprachondylar/Epichondylar

Modification

1 Per 2 Years

FalseP1561 - 7P-SA-301 $133.62 Each(0.75/0/0)

Syme's Posterior or Lateral Opening 1 Per 2 Years

FalseP1281 - 4P-SK-308 $509.02 Each(2.5/53/6)

Syme's PTB Design 1 Per 2 Years

FalseP1271 - 4P-SK-307 $44.26 Each(0.25/0/0)

Thermolyn Insert/ Thermo Plastic Lining 1 Per 2 Years

FalseP9341 - 7 $360.88 Each(1.25/124/0)

##Stubbies

Stubbies 2 Per 3 Years

False

Prior Approval to establish contributionSubmit hours and material costs to the AADL Manager

P7171 - 4Laminated or Non-Laminated Sockets with crepe bottom Prior Approval

##Suction- Suspension Sleeves

A combination of any suction suspension sleeves can be provided to a maximum of $914.28 per year or a maximum quantity of 6 per year. The maximum price and quantity maximum for each of the sleeves is noted. When providing a variety of sleeves, the Specialty Supplier is responsible to ensure the client is not provided with more than 6 suspension sleeves/per year or not to exceed a total cost of more than $914.28 per year. AADL will be closely monitoring the clients who receive more than one type of suspension sleeve. The rationale for providing different types of suspensions sleeves must be indicated in the E-Business Benefit Note. If the quantity maximum or dollar maximum is exceeded, AADL will take a credit if a QFR has not been submitted and approved.

Contex Gel Sleeve 6 Per 12 Months

TrueP6491 - 43 mm Transtibial Gel Sleeve $146.83 Each(0.05/115/9)

Easy Sleeve - heavy duty 6 Suction Sleeves Per Limb Per 12 Months

TrueP1661 - 4SFR-24-6HP $103.49 Each(0.05/76/9)

Generic Suction Sleeve 6 Suction Sleeves Per 12 Months

False

See Generic Pricing Procedure

N1001 - 7 $247.59 Max. Each(0.05/205/9)


Page 6 of 35



APL P-5



Functional



##Suction- Suspension Sleeves


Ossur Iceflex Endurance sleeve 6 Suction Sleeves Per Limb Per 12 Months

TrueE5052 - 4F-0107XX $149.03 Each(0.05/117/9)

##Tension- Suspension Sleeves


Generic Tension Sleeve 12 Tension Sleeves Per 12 Months

True


N1101 - 7 $77.17 Max. Each(0.05/52/9)

Neoprene Sleeve 12 Per 12 Months

False

Heavy duty or equivalent (no Rx required)

P1581 - 4DKS316 $86.70 Each(0.05/61/9)

##Suspension Belts

Pelvic Belt 1 Per 12 Months

FalseP1731 - 4Light $375.07 Each(1.25/118/21)

FalseP1741 - 4Padded $595.11 Each(2/185/33)

PTB Cuff 1 Per 12 Months

FalseP2041 - 4 $315.80 Each(1.5/38/6)

Silesian Belt 1 Per 12 Months

TrueP1791 - 4 $304.46 Each(1.25/67/7)

TES Belt 2 Per 12 Months

TrueP1821 - 421B37 $186.96 Each(0.4/101/2)

Waist Belt 1 Per 12 Months

FalseP1711 - 4Padded $509.28 Each(2/119/21)

FalseP1701 - 4Standard $236.85 Each(1.25/12/2)


Page 7 of 35



APL P-6



Functional



##Additions to Suspension

Fork Strap 1 Per 12 Months

FalseP1671 - 4 $244.60 Each(1/52/9)

Ottobock Gator Sleeve Protector 6 Per 12 Months

True

Not required for P153, P155 - c/w sleeves.

P0411 - 4 $25.45 Each(0.05/12/2)

###Gel Cushion Liners - Custom

Clients are eligible for either a Gel Cushion Liner OR a Gel Locking LinerReplacement Criteria- Standard size: minimum at 2 cm distal shrinkage- Custom made: document distal circumferences by CAD printout indicating shape and volume changesAll liners have a 6 month minimum manufacturer's warranty coverage.

Alpha Design Cushion Liner 1 Custom Liner Per 12 Months

FalseP7252 - 4, 6 - 7, or 9Duplicate $652.38 Each(0.75/375/99)

FalseP7242 - 4, 6 - 7, or 9Initial $1,020.33 Each(1.5/585/99)

Generic Custom Gel Cushion Liner 1 Custom Liner Per 12 Months

False


N1211 - 7, or 9 $1,497.45 Max. Each(1.5/1011/99)

Ottobock Custom Made TEC 1 Custom Liner Per 12 Months

FalseE7141 - 4 Partial Foot/Ankle Disarticulation $1,497.45 Each(1.5/1011/99)

FalseE7131 - 7, or 9Transfemoral/Syme's/Above Elbow $1,613.95 EachEach

(2/1036/99)

FalseE5041 - 4Transtibial $1,497.45 Each(1.5/1011/99)

###Gel Cushion Liners - Standard


Generic Standard Gel Cushion Liner 2 Liners Per 12 Months

False


N1201 - 4 $746.86 Max. Each(0.75/532/18)

Iceross TF Seal-in Liner 2 Per 12 Months

True

No pins, no locking systems or sleeves

P0561 - 4 $870.06 Each(0.75/642/18)


Page 8 of 35



APL P-7



Functional



###Gel Cushion Liners - Standard


Ohio Willow Wood Alpha Cushion Liner 2 Liners Per Limb Per 12 Months

TrueE7151 - 4 $473.71 Each(0.75/288/18)

Ottobock Simplicity Liner 2 Liners Per Limb Per 12 Months

TrueE5221 - 7, or 9With and without cover, no lock. $761.42 Each(0.75/545/18)

###Gel Locking Liners - Custom


Alpha Design Cushion Liner - Locking 1 Custom Liner Per 12 Months

FalseP7272 - 4Duplicate $722.38 Each(0.75/437/99)

FalseP7262 - 4Initial $1,058.41 Each(1.5/619/99)

Generic Custom Gel Locking Liner 1 Custom Liner Per 12 Months

False


N1311 - 7 $1,058.41 Max. Each(1.5/619/99)

###Gel Locking Liners - Standard


Generic Standard Gel Locking Liner 2 Liners Per 12 Months

True


N1301 - 7 $817.42 Max. Each(0.75/595/18)

Iceross Dermo/Stabilo Liners 2 Liners Per 12 Months

TrueE5181 - 7 $651.66 Each(0.75/447/18)

Ohio Willow Wood Alpha Cushion Liner

With Lock

2 Liners Per 12 Months

TrueP6461 - 4, 6 or 7 $544.26 Each(0.75/351/18)


Page 9 of 35



APL P-8



Functional



###Gel Locking Liners - Standard


Ossur Iceross Comfort Liner 2 Liners Per 12 Months

TrueE7161 - 71-5006XX $624.78 Each(0.75/423/18)

###Additions to Liners

Alpha Gel Cup 2 Per 12 Months

FalseP7201 - 4, 6 or 7 $103.23 Each(0.25/44/8)

Iceross Pads 2 Pads Per Limb Per 12 Months

FalseE5171 - 7, or 9 $111.13 Each(0.25/52/8)

Molded Distal Cushion 1 Per 12 Months

FalseP6941 - 7 $92.96 Each(0.5/3/0)

Ossur Iceross Silicone Distal Cap 2 Per 12 Months

TrueP7131 - 71-3000XX $299.98 Each(0.75/133/18)

Ottobock TEC Spots 2 TEC Spots per limb Per 12 Months

FalseE7041 - 7 $78.63 Each(0.25/22/8)

###Spacer Socks

Filler Cast Sock - 1 Ply 12 Socks Per 12 Months

TrueP2181 - 7, or 9 $20.52 Each(0.05/7/2)

###Socket Inserts- Lower and Upper

Kemblow Liner - Transtibial 1 Per 2 Years

FalseP1431 - 4 $589.57 Each(3/46/6)

Leather Socket Knee Disarticulation - KD 1 Per 2 Years

FalseP3561 - 4 $501.03 Each(2/113/20)

Liner - Transfemoral 1 Per 2 Years

FalseP1471 - 4P-SK-317 $421.78 Each(2.25/14/7)

Pelite Liner 1 Per 2 Years

FalseP4745 - 7, or 9TR, TH $270.34 Each(1.5/2/1)

FalseP1451 - 4Transtibial TFSK-316 $366.45 Each(2/7/3)


Page 10 of 35



APL P-9



Functional



###Socket Inserts- Lower and Upper

Silicone or Equivalent 1 Per 2 Years

FalseP1491 - 7, or 9 TT, TR, TH SK-318 $841.54 Each(4/109/10)

FalseP1511 - 4TF SK-319 $890.40 Each(4.25/106/19)

Symes/Knee Disarticulation Stovepipe

Liner

1 Per 2 Years

FalseP9351 - 7 $558.33 Each(3/24/0)

###Additions to Socket Inserts

Expandable Wall Socket 1 Per 2 Years

FalseP1251 - 7 $677.68 Each(3.5/45/7)

Full Leather Lining 1 Per 2 Years

FalseP9331 - 7 $215.84 Each(1/34/0)

Ischial Containment 1 Per 2 Years

FalseP9321 - 4 $177.00 Each(1/0/0)

Suprachondylar Liner Buildup 1 Per 2 Years

FalseP9301 - 4 $132.75 Each(0.75/0/0)

###Suction Valves

Generic Suction Valves 1 Suction Valve Per 2 Years

False


N2201 - 7 $275.22 Max. Each(0.5/159/8)

Icelock Expulsion Valve 1 Per 2 Months

TrueP0591 - 4TF 542 $175.79 Each(0.25/110/8)

TrueP0581 - 4TT 541 $154.51 Each(0.25/91/8)

Ossur Valve 1 Per 2 Years

FalseP3111 - 7641 $174.42 Each(0.5/69/8)

Ottobock Thermal Valve 1 Per 2 Years

TrueP1751 - 421Y12 $285.30 (0.5/168/8)

TEC V5 Expulsion Valve Kit 1 Per 2 Years

FalseP1401 - 7 $165.86 Each(0.5/61/8)

Valve Parts 1 Valve Part Per 2 Years

True


N1651 - 7 $131.29 Max. Each(0.25/70/8)


Page 11 of 35



APL P-10



Functional



###Lock Systems

Fillauer Shuttle Lock 1 Shuttle Lock Per 2 Years

FalseE7351 - 7 125234 $269.29 Each(0.75/114/8)

Generic Lock Systems 1 Per 2 Years

True


N2501 - 7 $538.99 Max. Each(0.75/355/8)

Icelock Clutch 1 Per 2 Years

FalseP1361 - 7211 $315.55 Each(0.75/155/8)

TrueP1371 - 7214 $368.75 Each(0.75/203/8)

Locking Lanyard 1 Per 2 Years

FalseP0791 - 7 $364.27 Each(0.75/199/8)

Ossur Ratchet 1 Per 2 Years

TrueP0941 - 7621 $301.55 Each(0.75/143/8)

Pro Advantage Locking Kit 1 Per 2 Years

FalseP8661 - 7 $265.22 Each(0.75/110/8)

###Additions to Lock Systems

Attachment Pin Icelock 1 Per 2 Years

FalseP1381 - 7, or 9211 & 214 $96.57 Each(0.25/39/8)

Fillauer Clutch Lock Pin 1 Clutch Lock Pin Per 2 Years

FalseE7361 - 7 $88.39 Each(0.25/31/8)

###Blocks and Laminate-in Adaptors

Generic Blocks and Laminate-in Adaptors 1 Per 2 Years

False

See generic pricing procedure

N2701 - 7, or 9 $540.09 Max. Each(0.25/435/8)

Ossur Alloy 4-hole 1 Per 2 Years

FalseP3161 - 4674 $111.13 Each(0.25/52/8)

Ossur Titanium 1 Per 2 Years

TrueP5461 - 44-Hole 675 $404.64 Each(1.25/132/35)

Ottobock Attachment Block 1 Per 2 Years

FalseP7111 - 45R1 $152.45 Each(0.5/49/8)

Ottobock Laminated Pyramid 1 Per 2 Years

FalseP8451 - 44R100 $262.90 Each(0.5/148/8)


Page 12 of 35



APL P-11



Functional



###Blocks and Laminate-in Adaptors

Ottobock Socket Adaptor 1 Per 2 Years

FalseP2111 - 7, or 94R41 $258.42 Each(0.5/144/8)

Ottobock Threaded Ring w/ Lamination

Anchor 4-Prong

1 Per 2 Years

FalseP4141 - 44R111 $249.46 Each(0.5/136/8)

###Distal Socket Adaptors

Generic Distal Socket Adaptors 1 Per 2 Years

False


N2601 - 4 $517.69 Max. Each(0.25/415/8)

Ossur 4-hole Male Pyramid Adaptor 1 Per 2 Years

TrueP7311 - 4A233100 $107.77 Each(0.25/49/8)

Ottobock 4 Bolt Pyramid 1 Per 2 Years

FalseP6851 - 44R54 $143.34 Each(0.25/80/8)

Ottobock Rotatable Pyramid With Hole 1 Per 2 Years

FalseP6811 - 44R77 $241.05 Each(0.25/168/8)

Ottobock Rotator 1 Per 2 Years

FalseP6841 - 44R51 $200.73 Each(0.25/132/8)

###Knee Axial Rotators

Ottobock A/K Rotation Adaptor 1 Per 2 Years

FalseP6881 - 44R57 $752.89 Each(0.25/625/8)

###Proximal Knee Adaptors

Generic Proximal Knee Adaptors 1 Knee Adaptor Per 2 Years

False

See Generic Pricing Procedure - Max. $347.45

N2301 - 4 $347.45 Max. Each(0.25/263/8)

Ossur Total Knee Pyramid 1 Per 2 Years

FalseP6801 - 422 $279.14 Each(0.5/162/8)

Ottobock Pyramid Adaptor 1 Per 2 Years

FalseP6901 - 44R50 $301.53 Each(0.25/222/8)

###Proximal Knee Procedures

Thigh Lacer 1 Per 2 Years

FalseP1641 - 4 5-902A $571.24 Each(2.5/104/11)


Page 13 of 35



APL P-12



Functional



###Proximal Knee Procedures

Thigh Lacer 1 Per 2 Years

FalseP1651 - 4With gluteal/ischial moulding $927.04 Each(4.5/104/13)

###Knee Systems

Daw Teh-Lin Knee 1 Knee Per 2 Years

FalseP5603 - 4 4 Bar Pneumatic TGK-4P00 $3,400.35 Each(2.63/2588/35)

FalseP5613 - 4Graphlite Pneumatic TGK-4P10 $3,592.65 Each(2.63/2760/35)

Generic Knee 1 Knee Per 2 Years

False


N1511 - 4Friction $3,269.35 Max. Each(2.05/2563/35)

False


N1533 - 4Hydraulic $4,973.22 Max. Each(2.63/3993/35)

False


N1542 - 4Hydraulic $3,827.46 Max. Each(2.63/2970/35)

False


N1501 - 4Knee/Shin $1,436.81 Max. Each(3.5/698/35)

False


N1521 - 4Locking $1,612.59 Max. Each(2/1092/35)

False


N1562 - 4Multifunctional $5,694.77 Max. Each(3.22/4544/35)

Hosmer Durathane Knee Shin for Mauch

SNS

1 Per 2 Years

FalseP0462 - 434932 $1,160.45 Each(3.5/451/35)

Medial Lateral Support With BK Suction

Socket

1 Per 2 Years

FalseP7232 - 4 $1,855.22 Each(9/193/45)

Ossur Mauch Graphite Frame With

Hydraulic SNS

1 Per 2 Years

FalseP2473 - 4FRM01804U $4,141.06 Each(2.63/3250/35)

Ossur Gaitmaster Knee With Mauch SNS

(250-350 lbs.)

1 Per 2 Years

FalseP8762 - 4MKN0136 $4,475.94 Each(2.63/3549/35)

Ossur Total Knee 1 Knee Per 2 Years

TrueP9522 - 4Hydraulic 2000 $3,571.25 Each(3.22/2648/35)


Page 14 of 35



APL P-13



Functional



###Knee Systems

Ossur Total Knee 1 Knee Per 2 Years

False

High impact, multi speed, heavy duty weight up to 275 lb, knee disarticulate, with heavy use.Note criteria on client benefit note.

P9794Hydraulic 2100 $6,530.29 Each(3.22/5290/35)

FalseP9732 - 4Pediatric 1100 $2,134.40 Each(2.05/1550/35)

Ottobock Knee 1 Knee Per 2 Years

FalseP9603 - 4EBS 3R60 $5,694.77 Each(3.22/4544/35)

FalseP9673 - 4Hydraulic 3R45 $3,839.78 Each(2.63/2981/35)

TrueP9763 - 4Hydraulic Knee Disarticulation Titanium 3R46 - to 275 lbs. $3,671.78 Each(2.63/2831/35)

TrueP0443 - 4Pneumatic 3R106=1 $2,512.58 Each(2.63/1796/35)

TrueP5661 - 4Polycentric 4 Bar 3R36 $1,838.72 Each(2.05/1286/35)

FalseP9502 - 4Polycentric Child's Knee 3R66 $1,718.88 Each(2.05/1179/35)

FalseP9683 - 4Single Axis Hydraulic 3R80 $5,408.05 Each(3.22/4288/35)

TrueP5651 - 4Single Axis Locking 3R33 $1,385.23 Each(2/889/35)

###Knee Side Joint

Generic Knee Side Joint 1 Knee Side Joint Per 2 Years

False


N1591 - 4 $1,137.74 Max. Each(3.5/455/8)

Ottobock Side Joints 1 Knee Side Joint Per 2 Years

TrueP9361 - 47U26 $954.06 Each(3.5/291/8)

###Microprocessor Knees

AADL provides a grant to those clients who are at least a Functional Level 3 and want to upgrade to a microprocessor knee. The grant will be paid directly to the Specialty Supplier once the microprocessor knee has been provided to the client (service date). The individual will own the microprocessor knee. AADL will not pay for repairs or maintenance of a microprocessor knee. The quantity/frequency limit of one microprocessor knee grant per five years will be strictly enforced. A client declaration for the microprocessor knee must be completed and signed prior to the authorization being submitted. A copy of this declaration must be kept on the client file in addition to the AADL client declaration form. AADL will not replace any prosthetic knee provided within 2 years due to client preference.

Microprocessor Knee 1 Microprocessor Knee Per 5 Years

FalseP9253 - 4 $6,000.00 Grant(0/0/6000)


Page 15 of 35



APL P-14



Functional



###Knee Caps

Ossur Knee Cap 1 Cap Per 2 Years

FalseP1261 - 4Large $206.90 Each(0.5/98/8)

FalseP1241 - 4Small $167.70 Each(0.5/63/8)

###Knee Extension Assists

Total Knee Extension Assist 1 Per 2 Years

FalseP1292 - 4 $203.54 Each(0.5/95/8)

###Shin Ferrules

Ossur Shin Ferrule 1 Per 2 Years

FalseP1231 - 4 $141.10 Each(0.5/39/8)

###Additions to External Knee Joints

Back Check 1 Per 12 Months

FalseP1681 - 4 $192.60 Each(1/12/2)

Joint Covers 1 Pair Per 12 Months

FalseP1621 - 4 $102.15 Pair(0.5/11/0)

###Hydraulic Cylinders

Catech SNS Hydraulic Cylinder -

Replacement Only

1 Per 2 Years

FalseP9653 - 4500R $1,855.26 Each(0.5/1569/8)

Ossur Mauch 1 Per 2 Years

FalseP7153 - 4SNS00100U - Cylinder SNS69571 - Black Replacement only $2,096.34 Each(0.5/1785/8)

###Modular Adaptors/connectors - Adjustable

Generic Adaptor/Connectors - Fixed 1 Per 2 Years

False


N2901 - 4 $1,309.53 Max. Each(0.25/1122/8)

Generic Components 1 Per 2 Years

False


N2401 - 4 $476.82 Max. Each(0.5/339/8)

Ottobock Slide Adaptor 1 Per 2 Years

FalseP8151 - 44R103 $396.18 Each(0.5/267/8)


Page 16 of 35



APL P-15



Functional



###Modular Adaptors/connectors - Fixed

Ottobock 4R72 Double Tube Adaptor -

female

1 Per 2 Years

FalseP8031 - 4 $244.41 Each(0.25/171/8)

Ottobock Double Pyramid Adaptor 1 Per 2 Years

FalseP8331 - 44R84 $236.57 Each(0.25/164/8)

###Tube Clamps

Generic Tube Clamps 1 Tube Clamp Per 2 Years

False


N2101 - 4 $347.45 Max. Each(0.25/263/8)

Ottobock Tube Clamp 1 Tube Clamp Per 2 Years

FalseP8021 - 434 mm 4R82 $211.93 Each(0.25/142/8)

FalseP1101 - 7, or 94R52 P-LC-336 $211.93 Each(0.25/142/8)

FalseP8221 - 4Sliding Tube Clamp - 34 mm 4R88 $391.70 Each(0.5/263/8)

###Tubes

Generic Tubes 1 Tube Per 2 Years

False


N2001 - 7, or 9 $477.37 Max. Each(0.25/379/8)

Ottobock 2R37 Pipe 1 Tube Per 2 Years

FalseP1081 - 7, or 9Long P-LC-338 $205.21 Each(0.25/136/8)

FalseP1071 - 7, or 9Short P-LC337 $185.05 Each(0.25/118/8)

###Torque and Shock Absorbers

Century Total Shock 1 Per 2 Years

FalseP8513 - 422 4400/4410 $1,272.05 Each(0.5/1025/35)

Generic Shock Absorber 1 Shock Absorber Per 2 Years

False

See Generic Pricing Procedure - Max. $1765.97

N1223 - 4 $1,765.97 Max. Each(0.5/1466/35)

Ottobock 4R40 Torsion Plate 1 Per 2 Years

FalseP9712 - 4 $747.89 Each(0.5/557/35)

Ottobock Torsion Tube 1 Per 2 Years

FalseP2032 - 44R39 $747.89 Each(0.5/557/35)


Page 17 of 35



APL P-16



Functional



###Torque and Shock Absorbers

Ottobock Torsion Tube Clamp 1 Per 2 Years

FalseP8272 - 44R85 $671.73 Each(0.5/489/35)

###Vacuum Suspension Systems and Replacement Components

Criteria

Must be a non-neuropathic client with full cognitive ability.

Must have reasonable volume management and stump shaping.

Socket Replacement Crriteria

Shrinkage of 3-5 ply as per Otto Bock.

Generic Vacuum System 1 Electric Vacuum System Per 2 Years

False


N1603 - 4Electric $2,875.92 Max. Each(4.05/1896/35)

False


N1613 - 4Standard $3,739.82 Max. Each(3.47/2759/35)

Ottobock Barbed Elbow Connector 1 Per 2 Years

True

Connects suction supension socket to vacuum hose at 90 degrees

P7193 - 44Y350 $145.31 Each(0.25/58/35)

Ottobock Expulsion Valve With Filter 1 Per 2 Years

FalseP6483 - 44Y345 $139.16 Each(0.25/53/35)

Ottobock Harmony System 1 Electric Vacuum System Per 2 Years

False

(1 year warranty) includes cost of V5 valve kit & shock absorbers

P9203 - 4Heavy Duty 4R150 $3,589.74 Each(3.47/2625/35)

True

(1 year warranty) includes cost of V5 valve kit & shock absorbers

P9213 - 4P2 (with pyramid and tube clamp) 4R144 $3,678.22 Each(3.47/2704/35)

###Ankles

Any comparable quality system to below listed items may be substituted with AADL prior approval.

Endolite Attachment Plate/Bolt 1 Ankle Per 2 Years

FalseP8712 - 4 $190.61 Each(0.25/115/17)

Endolite Snubber 1 Ankle Per 2 Years

FalseP2122 - 4Heavy Duty $388.30 Each(0.5/252/17)

FalseP2052 - 4Standard $388.30 Each(0.5/252/17)

Ohio Willow Wood Impulse Ankle 1 Ankle Per 2 Years

FalseP0872 - 4 $394.18 Each(0.5/257/17)


Page 18 of 35



APL P-17



Functional



###Ankles

Any comparable quality system to below listed items may be substituted with AADL prior approval.

Ottobock Child SACH Adaptor With

Pyramid

1 Ankle Per 2 Years

FalseP8742 - 42R40 $148.88 Each(0.25/77/17)

Ottobock SACH 1 Ankle Per 2 Years

TrueP5561 - 4Adaptor With Pyramid Titanium 2R31 $174.65 Each(0.25/101/17)

FalseP1901 - 4Shaped Wood Ankle Block 2K35 $267.63 Each(0.75/105/17)

Ottobock Single Axis Ankle 1 Ankle Per 2 Years

FalseP8671 - 4Aluminium 2R51 $390.26 Each(0.5/254/17)

TrueP5551 - 4Titanium 2R33 $505.62 Each(0.5/357/17)

Trulife Ankle 1 Ankle Per 2 Years

FalseP5762 - 4Child's Ankle Block SAB313/312/311 $199.09 Each(0.75/43/17)

Truper Ankle 1 Ankle Per 2 Years

FalseP5922 - 4Endoskeletal Ankle $441.78 Each(0.5/300/17)

False

Growth in height/length, expect 3 yr. if start at size 16

P5931 - 4Exoskeletal Ankle $486.03 Each(0.75/300/17)

###Feet

College Park Trustep 1 Foot Per 2 Years

FalseP8902 - 4 $1,755.44 Each(2.13/1199/35)

Elation (aka Total Concept) 1 Foot Per 2 Years

FalseP9143 - 4 $2,277.36 Each(2.13/1665/35)

Flex Foot 1 Foot Per 2 Years

False

Shock/Torque Absorber Not Required

P3893 - 4Ceterus Foot $4,607.51 Each(3/3608/35)

FalseP0653 - 4LP Vari-Flex Foot $2,047.19 Each(1.88/1499/35)

TrueP0663 - 4LP Vari-Flex Pyramid $2,706.87 Each(1.88/2088/35)

False

Please note repair criteria at end of schedule. When repair involves removal of costmetic skin, AADL will pay for only 1 hour to remove and replace cosmetic skin without prior approval

P9093 - 4Modular III $3,055.19 Each(1.88/2399/35)

False

Please note repair criteria at end of schedule

P8854Reflex V.S.P. S/T $4,981.59 Each(3/3942/35)

FalseP9011 - 4Sure Flex With Pyramid $780.43 Each(0.88/526/35)


Page 19 of 35



APL P-18



Functional



###Feet

Flex Foot 1 Foot Per 2 Years

FalseP9003 - 4Variflex with split toe $2,047.19 Each(1.88/1499/35)

Freedom Innovations Renegade 1 Foot Per 2 Years

FalseP4753 - 4 $3,498.71 Each(1.88/2795/35)

Generic Foot 1 Foot Per 2 Years

False


N1713 - 4Adjustable $3,726.07 Max. Each(1.88/2998/35)

False


N1722 - 4Articulated $2,091.44 Max. Each(2.13/1499/35)

False


N1742 - 4Complex $4,981.59 Max. Each(3/3942/35)

False


N1701 - 4Permanent $3,039.37 Max. Each(6.22/1699/35)

False


N1731 - 4Simple $1,207.15 Max. Each(0.88/907/35)

Magnum Heavy Duty System 1 Foot Per 2 Years

FalseP8752 - 4250-350 lbs. $1,811.15 Each(3/1111/35)

Ottobock Foot 1 Foot Per 2 Years

TrueP0111 - 41C20 Pro Symes $3,100.97 Each(6.22/1754/35)

FalseP0263 - 41E50 Advantage DP2 $2,630.71 Each(1.88/2020/35)

TrueP5212 - 4Axtion 1E56 $2,213.52 Each(2.13/1608/35)

TrueP8912 - 4Child Dynamic 1K10 $433.23 Each(0.88/216/35)

FalseP9043 - 4C-Walk Carbon 1C40 $3,314.48 Each(2.13/2591/35)

TrueP5592 - 4Dynamic Foot With Toes 1D10 $521.71 Each(0.88/295/35)

FalseP5492 - 4Trias 1C30 $1,268.79 Each(1.88/804/35)

Springlite Chopart/Syme's 1 Foot Per 2 Years

FalseP9152 - 4 $2,259.85 Each(6.22/1003/35)

Trulife 1 Foot Per 2 Years

FalseP8932 - 4Lifecast SFH110 $504.57 Each(0.88/279/35)

Trulife Foot 1 Foot Per 2 Years

FalseP9052 - 4Carbon Lightfoot SCF185 $503.29 Each(0.88/278/35)

FalseP8942 - 4Child's Play SLF132 $478.31 Each(0.88/256/35)


Page 20 of 35



APL P-19



Functional



###Feet

Trulife Foot 1 Foot Per 2 Years

FalseP5502 - 4Lightfoot SLF160 $503.29 Each(0.88/278/35)

###Additions to Feet

Spectra sock can be provided in addition to other catalogue items in this group

College Park Trustep Foot Shell 2 Per 12 Months

FalseP2172 - 4 $162.65 Each(0.25/98/8)

Flex Foot Spectra Sock 3 Per 12 Months

FalseP2461 - 4 $70.81 Each(0.25/16/8)

Junior Foot Shell 2 Per 12 Months

FalseP0432 - 4 $198.59 Each(0.25/130/8)

Ossur Flex Foot Foot Shell 2 Per 12 Months

TrueP2652 - 4 $219.77 Each(0.25/149/8)

Ottobock Syme's Kit 1 Per 2 Years

TrueP1981 - 41P5 - 1P9 $634.28 Each(2.25/179/35)

Springlite Foot Shell 2 Per 12 Months

FalseP2152 - 4 $272.41 Each(0.25/196/8)

###Foot Plates

Silipos Comfortzone Double Socket Gel

Liner

6 Per 12 Months

FalseP6781 - 4 $107.88 Each(0.05/85/2)

Springlite Inserts 2 Per 12 Months

FalseP6751 - 4Foot Plate $264.45 Each(0.75/85/35)

###Hip Joints

Any comparable quality system to below listed items may be substituted with AADL prior approval

External Pelvic Joint 1 Hip Joint Per 2 Years

FalseP3921 - 4 $749.66 Each(3.5/108/8)

Hip Joint 1 Hip Joint Per 2 Years

FalseP8501 - 4TGH-01 $3,522.02 Each(3.25/2599/35)

Ottobock Hip Joint 1 Hip Joint Per 2 Years

FalseP8481 - 47E4 $1,314.16 Each(3.25/628/35)

FalseP8491 - 47E5 $1,423.92 Each(3.25/726/35)

FalseP8471 - 47E7 $2,466.64 Each(3.25/1657/35)


Page 21 of 35



APL P-20



Functional



###Hip Joints


Trulife Littig Hip Disarticulation System 1 Hip Joint Per 2 Years

FalseP7161 - 4Adult $2,110.14 Each(3.25/1338/35)

FalseP7141 - 4Pediatric - P28455 to P28464 $1,883.01 Each(3.25/1135/35)

###Additions to Hip Joints

Stainless Steel Pelvic Band 1 Per 2 Years

FalseP1771 - 4 $80.83 Each(0.25/24/8)

###Finishing

Endoskeletal Finish 1 Finish Per 2 Years

FalseP0821 - 4Hip Disarticulation (HD) P-CF-72 $1,673.99 Each(8/213/19)

FalseP0621 - 4Knee Disarticulation (KD) CF-42 $1,098.74 Each(4.75/213/19)

FalseP0341 - 4Proximal Femoral Focal Deficiency (PFFD) $1,054.14 Each(5/133/19)

FalseP5751 - 4Transfemoral (TF) $1,142.99 Each(5/213/19)

FalseP0521 - 4Transtibial (TT) $733.40 Each(3.5/88/14)

Exoskeletal Finish 1 Finish Per 2 Years

FalseP0131 - 4Ankle Disarticulation (AD) P-CF-21 $557.73 Each(3/20/3)

FalseP0251 - 4Knee Disarticulation (KD) P-CF-41 $1,514.28 Each(8/74/15)

FalseP0321 - 4Proximal Femoral Focal Deficiency (PFFD) P-CF-61 $1,514.28 Each(8/74/15)

FalseP0281 - 4Transfemoral (TF) $1,514.28 Each(8/74/15)

FalseP0191 - 4Transtibial (TT) $994.89 Each(5.25/47/12)

###Additions to Finishing

"Upgrade" indicates a product whose cost exceeds the AADL maximum contribution. Any additional cost is a client's choice and responsibility

Generic Cosmetic Skin - Silicone or

Equivalent

4 Cosmetic Skins Per 12 Months

False

Upgrade

N1831 - 4 AK $410.19 Max. Each(0.75/240/8)

False

Upgrade

N1821 - 4BK $342.99 Max. Each(0.75/180/8)

Ottobock Prosthetic Underhose 4 Per 12 Months

TrueP4951 - 499B14 TF $80.61 Each(0.25/24/8)


Page 22 of 35



APL P-21



Functional



###Additions to Finishing

"Upgrade" indicates a product whose cost exceeds the AADL maximum contribution. Any additional cost is a client's choice and responsibility

Ottobock Prosthetic Underhose 4 Per 12 Months

TrueP4881 - 499B16 TT $74.54 Each(0.25/19/8)


Page 23 of 35



APL P-22


###Upper Limb Prosthetic Benefits

Functional




Leather Socket 1 Per 2 Years

FalseP2845 - 7 $348.52 Each(1.75/30/4)

Split Socket Design 1 Per 2 Years

FalseP2815 - 7 $934.25 Each(4.75/74/9)

###Shrinker Socks - Upper Limb

Shrinker Sock - Upper Limb 3 Socks Per 12 Months

FalseP5345 - 7 $165.95 Each(0.05/137/2)

###Upper Limb Socket Procedures

Please refer to Lower Limb Prosthetic Benefits Section for the following:

Additions to Upper Limb Procedures

Suspension Sleeves and Additions to Suspensions

Gel Cushion Liners

Gel Locking Liners

Additions to Liners

Spacer Socks

Socket Inserts

Suction Valves

Lock Systems and Additions to Lock Systems

Blocks and Laminate-in AdaptorsPhysician Prescription Required (except P122).

Check Socket 2 Check Sockets Per 2 Years

FalseP1225 - 7, or 9Upper Extremity $652.74 Each(3.5/27/2)


FalseP2855 - 7Elbow Disarticulation (ED) $2,764.71 Each(15/87/11)

FalseP2945 - 7Fore Quarter $4,461.14 Each(24/170/21)

False


P2785 - 7Plastic Hand Socket With Wrist and 4 Fingers $3,440.02 Max. Each(18/216/11)

FalseP2905 - 7Shoulder Disarticulation (SD) $3,288.43 Each(17.75/118/13)

FalseP2875 - 7, or 9Transhumeral (TH) $2,548.57 Each(14/52/11)

FalseP2825 - 7Transradial (TR) $2,013.60 Each(11/50/10)

FalseP2805 - 7, or 9Wrist Disarticulation (WD) $2,273.37 Each(12.5/46/9)


Page 24 of 35



APL P-23



Functional



###Terminal Devices

Becker Imperial 2 Terminal Devices Per 2 Years

FalseP3516 - 750316 $961.40 Each(0.5/763/17)

Generic Terminal Device 2 Terminal Devices Per 2 Years

False


N1815 - 7Passive $718.42 Max. Each(0.5/547/17)

False


N1806 - 7Standard $1,798.38 Max. Each(0.5/1511/17)

Hosmer Terminal Device 2 Terminal Devices Per 2 Years

TrueP3156 - 7Hook - 55009 Model 5X $601.53 Each(0.5/442/17)

FalseP3346 - 7Hook 55059 Model 555 $610.40 Each(0.5/450/17)

FalseP3585 - 7Passive Hand $354.25 Each(0.5/221/17)

Ottobock Terminal Device 2 Terminal Devices Per 2 Years

FalseP3595 - 7Passive Hand 8K18 $718.42 Each(0.5/547/17)

FalseP7216 - 7Physolivo Baby Hand - Hand, glove and wrist unit 8K14=1 $1,512.56 Each(2/1019/17)

TrueP3616 - 7Voluntary Opening 8K23 $681.46 Each(0.5/514/17)

TRS Terminal Device 2 Terminal Devices Per 2 Years

FalseP3676 - 7Grip Adult $1,883.89 Each(0.5/1587/17)

FalseP5266 - 7Infant Hand-Passive $583.83 Each(0.5/426/17)

###Gloves for Hands

Generic Multi-Articulating Glove for

Myoelectric Hand

2 Gloves Per 12 Months

False


N1869 $1,132.81 Max. Each(0.75/885/8)

Hosmer Glove 2 Gloves Per 12 Months

FalseP3685 - 7, or 957586 $414.05 Each(0.75/243/8)

Leather Glove 2 Gloves Per 12 Months

FalseP3665 - 7NGL006-PR $420.55 Each(0.75/249/8)

Ottobock Glove 2 Gloves Per 12 Months

TrueP3645 - 7, or 98S5 $331.79 Each(0.75/170/8)


Page 25 of 35



APL P-24



Functional



###Gloves for Hands

Regal Passive Glove 2 Gloves Per 12 Months

FalseP8825 - 7 $656.59 Each(0.75/460/8)

###Hand Restoration

Partial Hand 1 Procedure Per 2 Years

FalseP3695 - 7Glove for Thumb or Finger $1,328.12 Each(4/464/99)

FalseP3705 - 7Multiple Fingers $1,339.09 Each(4/474/99)

Regal Custom Glove 1 Procedure Per 2 Years

False


N1855 - 7 $1,057.82 Max. Each(0.75/817/9)

###Wrist Units


Generic Wrist Unit 1 Wrist Per 2 Years

False

Requires flexion/extension capability combined with rotation/quick disconnect. Cannot be combined with P377.See Generic Pricing Procedure

N1407 $1,137.98 Max. Each(0.75/882/17)

Hosmer Wrist 1 Wrist Per 2 Years

FalseP3765 - 7CAPP Nylon Body 1-1/2" 55108 $197.90 Each(0.5/82/17)

FalseP3755 - 7CAPP Nylon Body 1-3/4" 55109 $197.90 Each(0.5/82/17)

FalseP3745 - 7CAPP Nylon Body 2" 55110 $197.90 Each(0.5/82/17)

FalseP8687Child Quick Disconnect Wrist 58151 $472.31 Each(0.75/287/17)

FalseP4006 - 7Flexion Friction Wrist 51100 FW 500 (2") $375.53 Each(0.5/240/17)

FalseP3885 - 7Nylon Friction Wrist - 52156 WE 200N (1-1/2") or 300N (1-3/4")

$199.97 Each

(0.5/84/17)

FalseP3875 - 7Nylon Friction Wrist - 52160 WE 500N $199.97 Each(0.5/84/17)

FalseP3837Quick Disconnect 52127 WD 400 $281.13 Each(0.75/117/17)

TrueP3807Quick Disconnect Wrist 51043 FM 100 $361.18 Each(0.75/188/17)

FalseP3867Quick Disconnect Wrist All Stainless 53896 WD 400SS $665.73 Each(0.75/460/17)

FalseP3827Quick Disconnect Wrist Stainless Steel 51044 FM 100S $642.05 Each(0.75/439/17)

FalseP3847Quick Disconnect Wrist Stainless Steel 52128 WD 400S $397.33 Each(0.75/220/17)

FalseP3955 - 7WE 100N Infant $185.24 Each(0.5/70/17)


Page 26 of 35



APL P-25



Functional



###Wrist Units


Hosmer Wrist 1 Wrist Per 2 Years

FalseP3905 - 7WE 200N 1-1/2" Nylon Friction 52147 $199.97 Each(0.5/84/17)

N-Abler Wrist Unit 1 Wrist Per 2 Years

False

Bi-lateral upper limb, used for dominant hand

P5277 $3,127.28 Each(0.5/2697/17)

TRS Wrist 1 Wrist Per 2 Years

FalseP5286 - 7Infant Wrist $174.08 Each(0.5/60/17)

###Additions to Wrist Units

Sierra Wrist Flexion - Friction Wrist 1 Per 2 Years

FalseP3776 - 752371 $495.43 Each(0.5/347/17)

Wrist Unit Inserts 1 Per 2 Years

FalseP4085 - 7Aluminum - 50527 $86.56 Each(0.25/22/17)

FalseP4095 - 7Stainless Steel - 50528 $139.20 Each(0.25/69/17)

###Elbows

Generic Elbow Hinge 1 Elbow Per 2 Years

False


N1906 - 7Single Axis Below Elbow $827.00 Max. Each(3.5/177/8)

Hosmer Elbow 1 Elbow Per 2 Years

FalseP4126 - 750606 E-200 $831.35 Each(1/552/35)

FalseP4116 - 750650 E-400 $912.55 Each(1/625/35)

FalseP4235 - 7External Locking Elbow Hinges 53885 $1,327.58 Each(3.5/624/8)

FalseP5076 - 7HD 50613 E-200 $893.06 Each(1/607/35)

FalseP5066 - 7HD 50653 E-400 $912.55 Each(1/625/35)

FalseP4205 - 7Outside Locking Hinge - Heavy Duty 50950 $1,669.52 Each(3.5/929/8)

FalseP4165 - 7Outside Locking Hinge 50776 $1,277.80 Each(3.5/580/8)

FalseP7376 - 7Power Bow 60665 E 400 $1,703.77 Each(1/1331/35)

FalseP4355 - 7Single Axis Below Elbow Hinge - Long 51856 $831.48 Each(3.5/181/8)

Ottobock Elbow 1 Elbow Per 2 Years

FalseE5086 - 7ErgoArm Elbow with Forearm - 12K42 $4,377.83 Each(1/3719/35)


Page 27 of 35



APL P-26



Functional



###Elbows

Ottobock Elbow 1 Elbow Per 2 Years

FalseP3326 - 7ErgoArm Elbow With Forearm 12K44 $4,638.79 Each(1/3952/35)

FalseE5125 - 7Modular 12R1 $557.49 Each(0.5/387/35)

###Shoulder Joint

Generic Shoulder Joint 1 Shoulder Joint Per 2 Years

False


N1915 - 7Abduction $672.78 Max. Each(1.5/331/35)

False


N1925 - 7Flexion - Abduction $666.51 Max. Each(1.5/326/35)

Hosmer Shoulder Joint 1 Per 2 Years

FalseP4445 - 7Abduction - Adult 51836 $683.59 Each(1.5/341/35)

FalseP4475 - 7Flexion Abduction - Adult 51010 $663.65 Each(1.5/323/35)

FalseP4495 - 7Universal - 52028 USJ-100 $647.58 Each(1.5/309/35)

###Universal Shoulder Joint

Generic Shoulder Joint 1 Shoulder Joint Per 2 Years

False


N1935 - 7Universal $666.51 Max. Each(1.5/326/35)

###Control Cables

Hosmer Cable Control 2 Per 2 Years

TrueP4556 - 755683 $349.78 Each(1.25/102/13)

Hosmer Elbow Cable 2 Per 2 Years

FalseP1695 - 750724 $242.68 Each(1.25/17/2)

Hosmer Hook To Cable Adaptor 2 Per 2 Years

FalseP4566 - 750444 $120.78 Each(0.5/26/2)

Teflon Lining 2 Per 2 Years

FalseP4546 - 7 $99.22 Each(0.5/7/2)

###Upper Limb Suspension/Gel Liners


Iceross Upper Limb 2 Per 12 Months

TrueP5335 - 7, or 9 $829.74 Each(0.75/606/18)


Page 28 of 35



APL P-27



Functional



###Upper Limb Suspension/Gel Liners


Ottobock 14Y1 Silicone Arm Liner 2 Per 12 Months

TrueP5295 - 7 $762.54 Each(0.75/546/18)

###Upper Prosthetic Suspension

Auxila Loop 2 Per 12 Months

TrueP5095 - 7, or 950115 $122.44 Each(0.5/27/2)

Elbow Hinge - Flexible Using Leather Or

Dacron

1 Per 2 Years

FalseP4765 - 7LH100 $92.02 Each(0.5/2/0)

Epicondylar Suspension 1 Per 2 Years

FalseP1155 - 7, or 9 $320.10 Each(1.5/42/7)

Expandable Wall Design 1 Per 2 Years

FalseP4835 - 7, or 9 $713.84 Each(3.5/75/9)

Flexible Elbow - Metal 1 Per 2 Years

FalseP4775 - 7HFH-6 $792.65 Each(3.5/146/8)

Harness 2 Per 12 Months

FalseP4685 - 7Chest $162.32 Each(0.5/56/10)

FalseP4625 - 7Figure 8 $351.56 Each(1.75/30/7)

FalseP4645 - 7Figure 8 With Olecrannon $395.81 Each(2/30/7)

FalseP4635 - 7Figure 9 $301.62 Each(1.5/26/6)

Hosmer 50752 Forearm Lift Assist 1 Per 2 Years

FalseP4786 - 7E46O R&L $306.02 Each(0.5/186/8)

Icelock Ratchet 1 Per 2 Years

FalseP5307 or 9721 $344.66 Each(0.5/221/8)

North Western Ring Harness 2 Per 12 Months

FalseP4605 - 7NRH-100 $415.01 Each(1.75/80/15)

Nudge Control 1 Per 2 Years

FalseP4806 - 752521 $423.79 Each(0.5/291/8)

Ottobock Lock Pin 1 Per 2 Years

FalseP532714A107 $126.26 Each(0.5/26/8)

Ottobock Lock Set 1 Per 2 Years

FalseP531714A1 $418.58 Each(0.5/287/8)


Page 29 of 35



APL P-28



Functional



###Upper Prosthetic Suspension

Shoulder Saddle 1 Per 12 Months

FalseP4665 - 7, or 9HD100L $778.73 Each(4/54/9)

Suction Housing 1 Per 2 Years

FalseP4795 - 720004 $120.75 Each(0.5/21/8)

Suction Procedure - Upper Limb 1 Per 2 Years

FalseP2495 - 7, or 9 $177.01 Each(1/0/0)

Tricep Cuff - Full 1 Per 12 Months

FalseP4705 - 7BEC 360 $273.39 Each(1.25/39/7)

Tricep Cuff - Half 1 Per 12 Months

FalseP4725 - 7BICEPS 320 $260.38 Each(1.25/29/6)

Tricep Cuff Laminated 1 Per 2 Years

FalseP4585 - 7BEC160 $329.33 Each(1.5/49/8)

###Upper Limb Finishing

Endoskeletal Finish 1 Per 2 Years

FalseP3045 - 7Fore Quarter (FQ) $1,283.04 Each(6.75/69/10)

FalseP3015 - 7Shoulder Disarticulation (SD) $1,283.04 Each(6.75/69/10)

FalseP2985 - 7Transhumeral (TH) $973.29 Each(5/69/10)

FalseP2795 - 7Transradial (TR) $629.03 Each(3.5/7/1)

FalseP2925 - 7With Forearm - Elbow Disarticulation (ED) $929.04 Each(4.75/69/10)

Exoskeletal Finish 1 Per 2 Years

FalseP2895 - 7Elbow Disarticulation (ED) $1,658.97 Each(9/52/6)

FalseP2775 - 7Transradial (TR) $859.53 Each(4.5/50/6)

FalseP3025 - 7With Arm Sections - Fore Quarter (FQ) $2,446.36 Each(13.25/81/9)

FalseP2995 - 7With Arm Sections - Shoulder Disarticulation (SD) $2,446.36 Each(13.25/81/9)

FalseP2935 - 7With Forearm - Transhumeral (TH) $1,703.97 Each(9.25/52/7)

FalseP2525 - 7Wrist Disarticulation (WD) $764.43 Each(4/46/4)


Page 30 of 35



APL P-29


###Upper Limb Myoelectric Prosthetic Benefits

Functional



###Upper Limb Myoelectric Prosthesis

Criteria - Adults

Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be discussed with AADL.Criteria - Children

Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.

Must be at least 2 years old.

1. Clients are eligible for a conventional OR Myoelectric prosthesis.2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by AADL. 4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception: Electrodes).5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for approval. AADL will provide the maximum contributions and client upgrade costs.6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement prosthetic device.7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.8. Repairs over $800 contact AADL for prior approval.

4 Channel Processor 1 Per 3 Years

FalseP8529Allows switching of operation modes for control with the wrist rotator or locking/unlocking the elbow

Prior Approval

Batteries 2 Per 2 Years

FalseP8139 Prior Approval

Battery Chargers 1 Per 4 Years


Battery Mounting Set 1 Per 3 Years


Connection Cables 3 Per 3 Years


Custom Upper Extremity Liner 1 Per 12 Months

True

For use with myeoelectric electrodes

P7229- Diagnostic liner (88L3=P)- TR Silicone liner with Ottobock fixation (88L1=BA) - TH Silicone liner with OB fixation (88L1=OA)

$1,800.12 Each

(2/1236/61)

Elbow 1 Per 3 Years


Electric Hands & Hooks 1 Per 3 Years


Electric Wrist Rotators 1 Per 3 Years



Page 31 of 35



APL P-30


###Upper Limb Myoelectric Prosthetic Benefits

Functional



###Upper Limb Myoelectric Prosthesis

Criteria - Adults

Must have a wearing pattern established by using a conventional prosthesis for at least 1 year - exceptions to be discussed with AADL.Criteria - Children

Must have had a body powered-activated terminal device for at least 1 year prior to Myoelectric fitting.

Must be at least 2 years old.

1. Clients are eligible for a conventional OR Myoelectric prosthesis.2. No replacement/repair of a conventional prosthesis for 2 years after a Myoelectric prosthesis has been provided.3. Wherever possible, Rehab involvement with the functional training of the Myoelectric device is supported by AADL. 4. AADL expectation is that recycled Myoelectric components should be used whenever possible (Exception: Electrodes).5. For Myoelectric benefits that are indicated as "Prior Approval" submit manufacturer's invoice costs to AADL for approval. AADL will provide the maximum contributions and client upgrade costs.6. Total cost of all repairs per device per three year period not to exceed 50% of the cost of a replacement prosthetic device.7. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.8. Repairs over $800 contact AADL for prior approval.

Electrodes 2 Per 3 Years


MyoWrist Flexion Unit 1 Per 3 Years

FalseP940910V40 Prior Approval

Recycle of Myoelectric Component 1 Per 12 Months

FalseP8649Cost of rebuilt component by manufacturer, shipping, plus labour hours to disassemble and install into new prosthesis

Prior Approval

Socket costs above conventional socket 1 Per 3 Years

FalseP8609ED finishing included $3,097.50 Each(17.5/0/0)

FalseP8629SH finishing included $4,779.00 Each(27/0/0)

FalseP8619TH finishing included $2,964.75 Each(16.75/0/0)

FalseP8599TR finishing included $1,991.25 Each(11.25/0/0)

FalseP8589WD Finishing Included $2,124.00 Each(12/0/0)

Switch Control 1 Per 2 Years


Wrist Units 1 Per 3 Years

FalseP8539Includes: Lamination Ring, Coupling Ring, Coaxial Plug Prior Approval


Page 32 of 35



APL P-31


###Prosthetic Soft Supplies and Fees

Functional



###Socks

Prosthetic Socks 12 Per 12 Months

False


P7831 - 7Custom-made $113.49 Max. Each(0.05/90/2)

False


P5831 - 7In Catalogue $40.01 Max. Each(0.05/25/2)

###Donning Aids

Easy Proth 2 Per 12 Months

FalseP4101 - 4 $73.22 Each(0.05/54/2)

###Sheaths

Daw Prosthetic Sheath 12 Per 12 Months

TrueP4891 - 7 $46.85 Each(0.05/31/2)

Prosthetic Sheath 12 Per 12 Months

TrueP4861 - 7, or 9 $26.29 Each(0.05/13/2)

Prosthetic Sheath In Catalogue 12 Per 12 Months

False

Dealer cost plus $11.73

P5801 - 7 $52.63 Max. Each(0.05/36/2)

Silo Sheaths 8 Sheaths Per Limb Per 12 Months

FalseE7002 - 7SA332 - Regular $49.70 Each(0.05/33/2)

FalseE7012 - 7SA333 - Active $71.03 Each(0.05/52/2)

###Other Fees

Consult with Client and Multidisciplinary

Team

4 Per 12 Months

False

One hour per client at $177.00Available to private prosthetic facilities only

P9371 - 7, or 9 $177.00 Per Hour(1/0/0)

Off-Site Facility Fee 1 Per 12 Months

False

One hour per client at $177.00Invoice for only one off site fee /per client/ per device. Available to all prosthetic facilitiesDocument on the benefit note: the name of off-site facility, device, and reason for off-site fee

P9381 - 7, or 9 $177.00 Per Hour(1/0/0)


Page 33 of 35



APL P-32



Functional



###Prosthetic Repairs

1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement prosthetic device.2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.3. Repairs over $800 contact AADL for prior approval4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be deducted from the initial procedure on the cost of the new device.5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and replace cosmetic skin. 6. Activities not considered a repair benefit:

trialling new components.

trimming/mods to NEW gel liners.

gait training.7. Shipping and Brokerage Fees where a device or component is:

under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials", and no "shipping or brokerage fees".

under warranty and being replaced, it must be provided under the appropriate AADL catalogue number (shipping and brokerage fees are already included).

not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included under P693/P857.

Labour 12 Hours Per 12 Months

False

Indicate on invoice # of hrs. & total $ of hrs. onlyDocumentation required:- Describe repair/mods.- # of hrs. and cost- Total cost of repair (hrs.+ materials)- % of total repair cost of device/component

P4921 - 7 $177.00 Per Hour(1/0/0)

Materials 6 Repairs Materials Per 12 Months

False

Invoice quantity = 1 per repair/modifications- Quantity of 1 is up to a maximum of $300Documentation required: - List of materials and cost

P6931 - 7 $300.00 Max. Each(0/267/0)

Myoelectric Labour 12 Hours Per 12 Months

False

Indicate on invoice # of hrs. & total $ of hrs.Documentation required:- Describe repair/mods.- # of hrs. and cost- Cost of materials- Total cost of repair (hrs.+ materials)- % of total repair cost of device/component

P8559 $177.00 Per Hour(1/0/0)


Page 34 of 35



APL P-33



Functional



###Prosthetic Repairs

1. Total cost of all repairs per device per two year period not to exceed 50% of the cost of a replacement prosthetic device.2. Total cost of repair to a component is not to exceed 50% of the AADL maximum contribution for that component.3. Repairs over $800 contact AADL for prior approval4. If a new device is prescribed within 3 months of a major repair ($800.00), 50% of the cost of the repair will be deducted from the initial procedure on the cost of the new device.5. For repairs to prosthetic feet that involve removal of cosmetic skin AADL will pay for only 1 hour to remove and replace cosmetic skin. 6. Activities not considered a repair benefit:

trialling new components.

trimming/mods to NEW gel liners.

gait training.7. Shipping and Brokerage Fees where a device or component is:

under warranty and is being replaced/repaired by the manufacturer, there should be no cost for "materials", and no "shipping or brokerage fees".

under warranty and being replaced, it must be provided under the appropriate AADL catalogue number (shipping and brokerage fees are already included).

not under warranty and being repaired by the manufacturer, shipping and brokerage fees may be included under P693/P857.

Myoelectric Materials 6 Repair Materials Per 12 Months

False

Invoice quantity = 1 per repair/modifications- Quantity of 1 is up to a maximum of $300Documentation required:- List of materials and cost

P8579 $300.00 Each(0/267/0)


Page 35 of 35



APL P-34

Documents

Alberta Aids to Daily Living Manual P - Prosthetic Benefits … · 2017-11-02 · Pricing effective April 1, 2015 ... Catalogue Number Information General Information Use the AADL