8. Prosthetic limbs
Prosthetic (artificial) limbs are devices that provide a portion of functions normally provided by natural arms and legs. They are often used when there is absence of part or all of a limb , for example due to an accident or birth defect, and help to improve function and quality of life.
Prosthetic limbs consist of a custom made socket which fits the residual limb and a terminal device made up of different components that assist in performing functional tasks and providing compatible cosmesis.
Prosthetic limbs vary considerably in their sophistication by virtue of their complexity, cost, and specialisation and due to the varying levels of function they provide. For example, a prosthetic limb may be a simple device that is functionally efficient, or an enhanced limb that is configured to have an appearance and functional performance that is similar to that of a natural limb.
The NDIA must be satisfied, amongst other matters, that the funding of a prosthetic limb represents value for money in that the costs of the support are reasonable relative to both the benefits achieved and costs of alternative support (section 34(1)(c)).
In considering whether a proposed prosthetic limb represents value for money, the NDIA will consider whether:
- the total labour and associated costs, including the number of hours and hourly rate of the prosthetist, represents value for money in the participant’s local market; and
- the cost of componentry proposed represents value for money when compared to the cost of similar prosthetic components that would meet the participant’s functional needs and goals.
The NDIA will generally fund definitive limbs only where they are specified (prescribed) by health professionals who are designated and accredited (where applicable) by the artificial limb service in the state or territory where the participant resides.
For upper and lower limbs, the specifications should propose the minimum level or grade of socket materials, componentry and coverings required that relate to:
- the participant’s weight;
- the participant’s goals and aspirations;
- the ability to use, put on and remove the limb;
- the ability to care for the limb; and
- the medical needs, that is, residual limb shape, fixed deformity to be accommodated, skin integrity and alignment-relevant co-morbidities.
In addition the necessity for a particular level of componentry should relate to factors that include:
- the participant’s expected or known functional level (based on standard measures such as the K classification);
- functional needs related to the environment of use, for example typical floor surfaces and gradients, the use of stairs, the amount of time walking, typical terrain if used outside, expected impacts; and
- the impact of actual or expected vocational demands on limb type.
Generally, the NDIA will fund:
- entry level or standard grade prostheses for participants up to K2 classification and will consider higher prosthesis for people up to K3 and K4 classification;
- repairs, maintenance, minor and major adjustments to prosthetic limbs (or prosthetic limbs funded by other systems prior to the participant joining the NDIS);
- ancillary costs related to prosthetic limbs such as residual limb socks and sheaths (typically 6 per year);
- limbs external to Osseo integrated implants; and
- upper limb myoelectric prostheses where the participant is either a bi-lateral amputee or has contralateral overuse syndrome which prevents the use of body powered prosthetics and where there is demonstrated commitment and success using a training device.
Generally, the NDIA will not fund:
- repairs due to damage resulting from use of a limb outside of recommended use and care guidelines;
- more than one prosthetic limb (i.e. a spare prosthetic limb), unless reasonable and necessary to do so having regard to any vocational demands or other relevant considerations (for a second limb for recreational use, recreational supports; and
- For K4 level, C-legs and computerised components unless reasonable and necessary to do so having regard to the functional benefits expected to be achieved and whether such benefits can be achieved in other ways.
Limbs will be replaced at typical replacement intervals unless more frequent replacement is warranted. Typical replacement periods are 3 years for most adults and, as needed, due to growth for children under 18 years of age (typically no more than bi-annually).
The NDIA may consider whether more frequent replacement is warranted on the basis of the participant’s needs.