Orthotics and prosthetics

Review all requests for replacements and repairs before approving them. Orthotics and prosthetics are not automatically replaced when the normal replacement period is reached.

Once the period has passed, there must be a need to replace the device. Such as:

• Deterioration of the orthotic or device jeopardizes the worker's safety.
• The device no longer meets the worker's orthotic or prosthetic needs, such as with significant weight loss or gain.
• It is not cost effective to repair the device.

The provider must give a valid reason for the replacement. WCB is not responsible for the cost of unauthorized orthotic or prosthetic devices provided to workers.

Repairs to orthotic and prosthetic devices are to be done within 14 business days from the date of authorization. In special circumstances, the WCB may extend the 14-day period.

The WCB is not responsible for the following:

• The cost of unauthorized prosthetic devices.
• Payment for repairs caused by abuse of the artificial limb. The worker is advised in writing when the prosthetic device is received that this is their responsibility.

Send a referral to Health Care Strategy for assistance locating out-of-province prosthetic and custom footwear services.

Contact the provider to arrange the prosthetic or custom footwear services once the referral coordinator has emailed the contact information. Share the provider’s information with the worker.

Once orthotics are approved, workers can receive services and products up to a total value of $3,000 from a contracted provider without additional approval from the decision maker. 

When a worker is seen by a non-contracted provider obtain approval from a WCB health care consultant.  If approved, the non-contracted provider, send the appropriate report and invoice to the provider to complete. (Review the Prosthetic and Orthotic Services (C998) report and the Prosthetic and Orthotic Services (C537) invoice)

Pre-approval from the decision maker is necessary for expenses over $3,000:

• For all new orthotics
• The cost of the repair to an orthotic
• The cost of replacing any orthotic device

The orthotic device (e.g., brace, orthotic, splint, etc.) must be required for activities of daily living and work.

Note: Orthotics are not limited based on the type of injury.
 

Multiple pairs

Approval may be given for more than one pair of orthotics, when prescribed as medically necessary by a physician or based on special circumstances, such as when the worker is working in a dirty environment and would not be expected to switch the orthotics from their work shoes to casual shoes.

Note: WCB does not pay for orthotic devices required for sporting activities. Exceptions may be made for severe injury when the device will improve a worker’s quality of life.

Approve off-the-shelf footwear one time when it is recommended to improve the results of the orthotics or a modification and supports a successful return to work.

Additional footwear is only provided if the worker's lack of appropriate footwear is a barrier to attending treatment or the worker requires a modification to more than one pair of footwear, like work boot and casual wear.

In the majority of situations, off the shelf footwear can be modified to meet the individual worker's needs.

Workers who cannot wear a modified or special off-the-shelf shoe for medical reasons may be eligible for custom footwear.

WCB only provides custom-made footwear when there is a medical reason, a prescription and a physician report related to the work injury, such as a structural deformity of the foot/ankle or a severe burn with extreme hypersensitivity.

Custom-made footwear can be approved once per year unless there are special circumstances, such as a dirty work environment that would require a second pair for dress or leisure. Custom footwear is only provided to workers who are able to walk.

Consult with the gait program when a worker makes a request for custom-made shoes and there are questions.

WCB does not provide custom-made footwear to a worker who is having problems finding appropriate off-the-shelf footwear for issues that can be resolved by a referral to an orthotist.

For example,

• Oversized or undersized feet, extra width or depth needs, a split size requirement, problems with edema or lesions, acute post-operative situations, etc.
• A leg length discrepancy – this is a need for an elevation and not custom-made footwear.
• Orthotics are creating a fitting problem.

Note: Custom footwear providers are not authorized to provide orthotics as a stand-alone service.

Refer the worker to the orthotist first. In many cases, custom-made footwear is recommended with an orthotics fitting, which may eliminate the need for the custom-made footwear. An orthotist can also customize off-the-shelf shoes when recommended.

Pedorthists (C.Ped) can only provide orthotics when required together with custom-made footwear or a modified shoe (including customization of off-the-shelf footwear).

If the worker has approval for both orthotics and custom-made shoes or off-the-shelf footwear that need to be modified, the worker can get both of these at a custom-shoe provider.

Non-orthotic and non-prescription braces are not considered a prosthetic or orthotic device.

Over-the-counter braces may be approved when recommended by a treating practitioner, such as surgeon, chiropractor, physiotherapist or podiatrist.

Once prosthetics have been approved, workers can receive services and products up to a total value of $6,000 from a contracted prosthetists without additional authorization from the decision maker.

When a worker is seen by a non-contracted provider, obtain approval from a WCB health care consultant.  If the non-contracted provider is approved, send the appropriate report and invoice to the provider to complete. (Review the Prosthetic and Orthotic Services (C998) report and the Prosthetic and Orthotic Services (C537) invoice).

Review requests to approve all costs over $6,000, such as:

• New prosthetics
• Prosthetic repairs
• The cost of replacing any prosthetic device

Prosthetic device supplies

The prosthetic provider may provide unlimited additional items as is reasonably necessary for a worker who is a new amputee for up to the first calendar year.

After the first year, a worker may receive the items listed below to the extent necessary to meet their needs in relation to an approved prosthetic device.

• Residual limb socks = 12
• Sheaths = 12
• Cosmetic Gloves = 4
• Prosthetic under hose = 4
• Suspension Knee Sleeves = 18

Approve additional quantities when environmental or physical conditions require.

A cosmetic prosthetic is considered for a worker whose physical appearance is an important factor in obtaining and maintaining employment, such as working with the public.

Cosmetic prosthetics are considered for injuries that have resulted in the amputation of one or multiple fingers and toes, hands and feet.

Note Ocular prosthetic devices are not contracted, so they are submitted under a custom invoice.

When a new amputee receives their first prosthetic device, the provider may provide as many additional items as is reasonably necessary during the first-year post-accident.

After the first-year post-accident, the decision maker must approve a request for additional items. The prosthetic provider must submit a valid reason for any additional items.

Multiple and additional limbs may be approved in special circumstances when the decision maker determines it is appropriate to approve devices to last a lengthy time period.

Consider:

• How often does an out-of-province worker come to Alberta?
• Is the work environment dirty, making it difficult to clean a prosthesis for everyday use?
• Limited access to a prosthetist if there is a problem with the prosthetic, such as living in a remote area.

In some cases, before or after a worker receives a prosthetic device, a physician may recommend the worker be referred to a specialist.

A specialist referral is required when the physician indicates any of the following circumstances:

• The worker does not have a treating specialist.
• Change in gait unrelated to another condition and/or causing lower back pain.
• There is reduced use of the prosthesis.
• The worker has an unrelated medical problem that is not presently managed and could affect the residual limb (uncontrolled diabetes, osteoarthritis in adjacent joint).
• Examination of the residual limb reveals persistent:
  • Incision breakdown and/or pain.
  • Scar retraction and/or tenderness, open ulceration and/or infection and other painful areas on residual limb.
  • Persistent swelling and pressure areas not improving with reduced prosthesis wear.
  • Neuroma develops.
  • Increased phantom limb dysesthesia or pain.
  • Substantial weight gain or loss affecting residual limb size or vascular problems.

When the worker’s capabilities with a prosthetic are not well established, or the problems cannot be resolved after multiple repairs or manufacturing and consultation, a specialist referral may be considered.

Contact the health care consultant to discuss care options for the worker when the family physician cannot complete a specialist referral.