Prostheses (POC 11)

This policy replaces the following policy: Treatment for the Good Limb (POC 11).

Purpose

This policy gives direction on the provision, repairs, adjustments, maintenance and replacements of prosthetic devices, prosthetic components,  associated supplies and accessories as well as services for missing limbs (arms and legs), parts thereof (hands and feet), and other body parts (eyes, ears, nose, etc.) for eligible clients.

Policy

Objective

1. The goal of a limb or other body part prosthesis is to enable eligible Veterans Affairs Canada (VAC) clients with amputations to meet their functional needs and to maximize their quality of life. Functional needs include physical needs such as optimal functioning in activities of daily living (ADL), instrumental activities of daily living (IADL), community and family roles as well as psychological needs such as appearance. These needs vary depending on the gender, age, interests, activities and other individual characteristics of the client.
2. The Canadian Armed Forces (CAF) is responsible for those members injured while serving and requiring prostheses, and provides benefits that are most appropriate, based on the needs of the members. VAC will continue to support the members once released, by maintaining and providing prosthetic devices to meet the ongoing and changing needs of VAC clients. VAC will also provide, maintain and replace initial prosthetic devices prescribed after release from the CAF.
3. In addition VAC will provide other services and supports related to having an amputation or prosthesis through other Programs of Choice (POC), e.g. POC 1 - Aids to Daily Living, POC 13 - Special Equipment, POC 12 - Related Health Services and POC 8 - Nursing Services.
4. A prosthetic device is a custom-made medical device designed to replace a missing body part (limbs, eyes, noses, ears, etc.). Related are prosthetic components, including but not limited to sockets, joints, covers, and terminal devices (hands and/or feet), etc., and accompanying supplies and accessories as necessary.
5. Various health professionals are involved in the prescription, recommendation, fitting, manufacture and support of prosthetic devices. The client’s attending physician or a relevant medical specialist (specialist physician) may prescribe a prosthesis. Medical specialists include, but are not limited to, a physiatrist, surgeon, orthopaedic surgeon, vascular surgeon, plastic surgeon, ophthalmologist (eye specialist), otolaryngologist (ear, nose and throat specialist), etc. Allied health professionals who may provide input into a request for a prosthesis and support for use of that prosthesis include, but are not limited to, occupational therapists, physiotherapists, mental health specialists etc. Prosthetists are experts in the recommendation, design, manufacturing and fitting of prosthetic devices.

Eligibility

6. The following clients may be eligible for benefits and services available through the prosthetics element of the Treatment Benefit Program if it is determined by a multidisciplinary rehabilitation team that the items are required and are the most reasonable intervention to meet the client’s needs:
   1. Clients who have a disability benefit entitled condition requiring prosthetic devices, called A-line coverage;
   2. Clients who have eligibility other than for disability benefit entitled condition who require some prosthetic items, called B-line coverage. These clients must first access provincial programs or private plans for provision of prosthetic devices and related supplies before approaching VAC; or
   3. Clients who are eligible for the VAC Rehabilitation Program, have an assessed rehabilitation need for a prosthetic device and have this documented as part of  their  rehabilitation plan. These benefits will be covered under the Rehabilitation Program if they are not otherwise available via other programs, i.e. a provincial health care system, a workers’ compensation plan or Service Income Security Insurance Plan (SISIP). Clients with eligibility under both the Veterans Health Care Regulations (VHCR) (i.e. disability benefits) and the Rehabilitation Program should first be considered for funding under the eligibility criteria for VHCR treatment benefits.
7. Benefits may be approved by the VAC decision-maker with guidance from the POC 11 - Prosthetics and Orthotics - Benefit Grids. When the client’s legitimate needs exceed the Benefit Grid limits, considerations may be made on an exceptional basis as defined in the business processes.

Requests for an initial prosthetic device

8. Requests for the initial issue of a prosthetic device should be prescribed by the client’s attending physician or the relevant medical specialist. Allied health professionals may provide input into the recommendation/prescription. This recommendation/prescription may be available on the client’s medical file either through CAF or the provincial/territorial health care system.
9. A prosthetic device should be designed, manufactured and fitted by a certified prosthetist, working in collaboration with the relevant medical specialist and the client. Allied health professionals may also provide input. Approval includes, where applicable, a trial period to ensure proper fitting and use.

Prosthetic devices for limbs

10. When a prosthetic device to replace a missing extremity, such as an arm or leg, or part thereof, is requested, eligible clients may be provided with:
    1. a primary device that meets the client’s everyday needs;
    2. a secondary basic device suitable as a back-up limb;
    3. an activity specific prosthetic device for activities of daily living (e.g. a shower or utility limb); and
    4. an activity specific prosthetic device, with consideration to the individual’s specific goals or requirements to engage in meaningful activity, such as, specific recreational activities, sports, hobbies, etc. The nature of this prosthesis depends on the age, sex, interests and other individual characteristics of the client.
11. Eligible clients may also be provided with a preparatory limb or socket, including but not limited to, when fitting an initial prosthetic device, following stump revision surgery while wounds are healing, during pregnancy, while undergoing medical treatments, etc.

Repairs, adjustments and maintenance

12. Most prosthetic devices and components have a warranty for normal use which allows for an appropriate life span. When the required repairs are beyond the warranty time period required repairs in lieu of a replacement limb may be authorized to maintain the limb in working order. Prescriptions for repairs are not required.
13. VAC clients who have received prosthesis from CAF will be provided with repairs and maintenance as outlined in this policy once they become a VAC eligible client.
14. If a client has an initial or replacement prosthesis provided through other means, VAC will consider repair if it can be determined that the client would be eligible for an initial or replacement prosthesis from VAC or CAF if the client were applying for such an item. Such requests must meet the guidelines required by VAC.
15. Prostheses and prosthetic components, such as but not limited to, sockets, joints, terminal devices (hands, feet), covers, corsets etc. may be adjusted or repaired on an as required basis when requested by the attending physician, a relevant medical specialist or a prosthetist. However, a prescription is not required.

Replacements

16. Scheduled limb prosthetic devices replacement will occur normally at the end of the life span of the current prosthesis (usually 3 years for lower limb and 5 years for upper limb). Replacement limbs may be considered in lieu of repairs if the limb is nearing the end of its projected life span.
17. Prostheses and prosthetic components, such as but not limited to, sockets, joints, terminal devices (hands, feet), covers, corsets, etc. may be replaced on an as required basis when requested by the attending physician, a relevant medical specialist or a prosthetist.
18. Early replacement of any limb prostheses or components requires a request with a rationale from the attending physician, a relevant medical specialist or a prosthetist.
19. Replacement of other body part prostheses should be as recommended by the attending physician or relevant medical specialist, usually every two years.
20. Replacement of prosthetic devices that VAC clients have received from CAF will require a request from a prosthetist or the attending physician. The recommendation from CAF will be accepted if completed within three years of the transition date to VAC.
21. Replacements differing in type or model are to be treated as a new request not a replacement and therefore should be prescribed by the client’s attending physician, a relevant medical specialist or prosthetist.

Supplies and accessories

22. Supplies and accessories,  such as but not limited to liners, socks, sheaths, stockinettes, sleeves, stump shrinkers, stump lotion and cream, etc., may be provided as needed  with no prescription required.

Follow-up

23. VAC coverage for prostheses includes follow-up visits with a prosthetist and if needed, other relevant medical specialists and allied health professionals to check the prosthetic alignment, fit, training on use, etc.

Addressing related health needs

24. Clients who live with amputations have numerous health needs for the amputation in addition to the need for prosthetic devices, which can be addressed through other VAC benefits and services. For example, aids to daily living, special equipment and home modifications can be addressed through POC 1 and POC 13 respectively. Mental health issues, gait training and fitness training for the increased energy needed to use a prosthesis (e.g. by a physiotherapist), ADL and IADL re-training (e.g. by an occupational therapist), weight control to ensure consistent socket fit, etc. can be addressed through POC 12 - Related Health Services. Wound management and foot care can be addressed through POC 8 - Nursing Services.
25. This policy also recognizes that the continuous stress a prosthesis places on other parts of the body, e.g. overuse of the opposite limb, shoulder use to control a manual prosthesis etc. may require special measures to improve the client's comfort and functioning for the amputation and prosthesis use. For example, prostheses, orthoses or other supports, such as knee braces and cages may be approved when required to enhance stability in the opposite limb.
26. Approval of prostheses, orthoses or other supports for the opposite limb does not infer that the client is eligible for a consequential disability benefits ruling.
27. Supplementary bracing or support may be approved when required to be worn over the prosthesis of the amputated limb(s).

References

Veterans Well-being Act, sections 8–9 and 16

Veterans Health Care Regulations, Section 4

POC 11 - Prosthetics and Orthotics - Benefit Grids