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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Scale of Fees

Annual Increase in Medical Tariffs for Medical Service Providers - 2024

Prosthetic and Orthotics Gazette 2024

Orthotic and Prosthetic Supply Protocol

 

ORTHOTIC & PROSTHETIC SUPPLY PROTOCOL

 

COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993

 

1.1 Each Medical Service Provider should ensure that the service they provide is compatible with the general procurement guidelines issued by National Treasury.

 

1.2 The Compensation Fund will bear the reasonable cost for the issue of Orthotic and Prosthetic devices after acquiring an occupational disease or sustaining an injury, provided that liability for the claim has been accepted, the service is prescribed by a medical practitioner and the prescribed guidelines are followed.

 

1.3 An employee as defined in the COID Act of 1993, is at liberty to choose their preferred medical service provider and no interference with this is permitted, as long as it is exercised reasonably and without prejudice to the employee or the Compensation Fund. For continuity of service and optimal rehabilitation outcomes it is advised that claimants consult with a medical service provider within their residential province.

 

1.4 The published policy on the Supply of Orthotic and Prosthetic devices and the tariff of fees will serve as a guideline to determine if any proposed service is reasonable and it will replace all existing tariff structures.

 

1.5 Pre-authorization by the Compensation Fund is required in all claims, even if the devices supplied are listed in the Government Gazette. It is the responsibility of the Medical Service Provider to ensure that liability for the claim has been accepted by the Compensation Fund and that the service is reasonable and in line with the published policy and tariff. All orthotic / prosthetic devices should be suitable for the environment and activity / load level of the employee.

 

1.6 Replacement of consumable items, refits and repairs must be motivated by the Medical Service Provider. All requests must be accompanied by photos of the Orthotic / Prosthetic Device to be replaced or repaired. Requests must be reasonable and in line with the published policy and tariff.

 

1.7 The employee, assisted by the Medical Service Provider should complete the appropriate form when requesting replacement, refit or repair of any Prosthetic / Orthotic device. Refer to Form 6- Request for Orthotic / Prosthetic Services

 

1.8 The request for new lower limb prosthetic equipment must be accompanied by a written report by the Medical Service Provider indicating that the employee's functional level has been re-evaluated to take into account any physical or environmental changes encountered by the employee. Refer to AMPPRO Test for Lower limb amputees

 

1.9 The request for primary (first time) wheelchair users must be accompanied by a written recommendation from an Occupation Therapist.

 

1.10 In exceptional circumstances, if the employment status and / or the functional level of an employee radically changes before a new assistive device is due, a new assistive device more suitable to the employment  conditions and / or functional requirements will be considered by the Compensation Fund.

 

1.11 If an employee's employment status / functional level changes and an assistive device in a higher category is requested, such higher functional level must be confirmed by the Employer and a rehabilitation team comprising of a Medical Doctor, the Prosthetist, a Physiotherapist and I or an Occupational therapist.

 

1.12 The Medical Service Provider must obtain written authorisation for all quotations of Orthotic or Prosthetic devices, refits, consumables and repairs. Accounts will not be payable for any Orthotic or Prosthetic device supplied to the employee without pre-authorisation and duly completed and signed confirmation of receipt.

 

1.13 The Compensation Fund will bear the reasonable cost of repairs to an assistive device which has suffered from "fair" wear and tear of normal use.

 

1.14 The Compensation Fund will not bear the cost of an orthotic / prosthetic device which is lost, broken, worn out or is otherwise unserviceable as a consequence of an employee's neglect or abuse.

 

1.15 The Compensation Fund will pay for the refit of a prosthesis strictly only where motivated and justifiable by the circumstances and within the published supply guidelines. Refer to Section 4 - Guidelines for  Refit

 

1 16 Replacement of consumables of Orthotic or Prosthetic devices that may perish or become consumed through reasonable usage will be paid for by the Compensation Fund in line with the supply guidelines. Refer to Section 3 - Replacement Period Table

 

1.17 The Compensation Fund reserves the right in terms of section 42 of the Act to call for a second or independent opinion or evaluation of proposed Orthotic/Prosthetic services.

 

1.18 Any such report obtained by the  Compensation Fund shall state  whether the  proposed Orthotic/Prosthetic service is appropriate for the diagnosis, functional level and environmental circumstances of the patient. The Compensation Fund reserves the right to use the information so obtained at its discretion and as is deemed appropriate.

 

1.19 The Commissioner is further entitled, pursuant to a complaint by the employee, to call for an independent report concerning any Orthotic/Prosthetic services that have been rendered.The Medical Service Provider should strive to take all reasonable steps to attend to the legitimate complaints of an employee regarding services or assistive devices supplied. If it is found that defective or unsuitable devices (not inline with pre-authorization) have been supplied to an employee the Medical Service Provider shall replace / repair / alter such devices at no additional cost to the Compensation Fund or the employee. The Compensation Fund reserves the right to decide on whether to maintain the said service provider on their data base of service providers or not.

 

1.20 The Orthotic and / or Prosthetic devices paid for by the Compensation Fund remains the property of the Compensation Fund.

 

1.21 Each request for Pre-authorization should be accompanied by a quotation on the Medical Service Provider's practice letterhead.

 

1.22 Every Medical Service Provider should supply the Compensation Fund with the rehabilitation report for all primary amputees.

 

1.23 Medical Service  Providers are required to quote a similar  or better component  using the same code.

 

1.24 The Compensation Fund retains the right to verify all products supplied to the employee.

 

1.25 Acknowledgement of receipt of Orthotic/Prosthetic device should be duly completed and signed by the Medical Service Provider, Injured Employee and Compensation Fund official (Form 8).

 

1.26 In order for the Compensation Fund to verify that the correct items were supplied, proof of purchase should accompany the acknowledgement of receipt for any single component/item in excess of R50 000.

 

2. Request for Orthotic / Prosthetic Services

The following details must accompany the request for orthotic I prosthetic services:

2.1 Orthotic / Prosthetic Service Request Form (Form 6)
2.2 Motivation for services by Medical Service Provider on practice letterhead
2.3 Quotation by Medical Service Provider according to published tariffs on practice letterhead
2.4 Doctor's Referral letter for any Primary Orthotic / Prosthetic device user
2.5 AMPPRO test (for Lower Limb Prosthesis only)
2.6 Refit report 4.1 - 4.12 (for refit of prosthesis only)
2.7 Quotation according to published tariffs (Form 7)
2.8 Photos of Orthotic / Prosthetic device to be replaced / repaired
2.9 Certified copy of ID / Valid temporary ID / Passport for foreigners valid within 6 months.

 

3. Replacement Periods of Medical Orthotic / Prosthetic Equipment

3.1

Prosthesis

Every Five years

Exceptions

3.1.1

Toe filler

Every Two and half years

3.1.2

Midfoot prosthesis

Every Two and half years

3.1.3

Chopart

Every Two and half years

3.1.4

Symes

Every Two and half years

3.1.5

Partial hand

Every Two and half years

3.1.6

Partial hand opposition post

Every Two and half years

3.2

Refit for prosthesis will be considered within 12 months after fitting of primary amputee with a prosthesis, and refit for returning amputees can be considered after two and half years from the fitting of a new prosthesis.

3.3

Silicone liners, gel liners

Two per year

3.4

Suspension sleeves

Two per year

3.5

Distal volume cup

Two per year

3.6

Prosthetic socks

Twelve per year

 
3.6.1 If worn with silicone or gel liners

Six per year

3.7

Prosthetic sheath

Twelve per year

 
3.7.1 If worn with silicone or gel liners

Six per year

3.8

Cosmetic stockings

Three pairs per year

3.9

Cosmetic foam cover

One per year

3.10

Cosmetic glove

One per year

3.11

Calipers

Every Two years

3.12

Manual Wheelchairs

Every Three years

3.13

Motorised Wheelchairs

Every Five years

3.14

Major Repairs to Motorised Wheelchairs

Every Two and a half years

3.15

Wheelchair cushions

Two per year

3.16

Motorised wheelchair batteries

One pair every 6 months

3.17

Orthopaedic footwear

Two pairs per year

3.18

Footwear modifications

Three modifications per year

3.19

Compression stockings

Four pairs per year

3.20

Off the shelf orthosis

Two per year

3.21

Custom made orthosis

Two every year

 

4. Guidelines for Refit

This guideline covers Prosthetic devices that require refit of the socket after the initial issue. A full motivation with a report indicating the following details must be submitted:

4.1 Date of amputation
4.2 Date when the present prosthesis was fitted
4.3 Description of the prosthesis
4.4 Residual limb measurements when prosthesis was fitted
4.5 Symptoms indicating loss of fit
4.6 Diagnosis of loss of fit
4.7 Current residual limb measurements.
4.8 Number and thickness of prosthetic socks and worn by employee
4.9 Condition of prosthesis
4.10 The employee's current activity level
4 .11 An opinion as to the suitability of the employees current prosthesis
4.12 Photos of the prosthetic device to be refit/repaired

 

5. Functional Level

A determination of the medical necessity for certain components / additions to a prosthesis is based on the potential functional ability of the employee. Potential functional ability is defined as  the reasonable expectation of the rehabilitation team including a Medical Doctor, the Prosthetist, a Physiotherapist and I or an Occupational therapist and the employee based on

• past history including prosthetic use
• current condition including the status of the residual limb and other medical factors
• employment status
• desire to ambulate

The clinical assessment for Lower Limb amputees should be based on the AMPPRO test results.

 

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