Could you please provide the NYSHIP - "The Empire Plan" orthotics policy? Hopefully, the policy will outline the criteria for medical necessity and specify the waiting period required when a patient needs a second pair. Does it state how many pair of orthotics a patient has benefits for? This plan does not require authorization for orthotics, but I do need the policy if it is available.
I do not see that what you are asking for is publicly available. There are some pieces of information available that are outdated and/or do not definitively apply to services performed in 2024. Unfortunately, I fear the safest way to get the information you are looking for is to call the phone number on the back of the card of the patient that is going to receive the service. This is undesirable, but I do not see any true coverage policies published that definitively address these exact questions.
The NY SHIP Empire Plan publishes its benefits here: https://www.pef.org/wp-content/uploads/2023/12/Empire-Plan-2024-at-a-glance.pdf
This says Empire coverage of this service is "administered" by United Healthcare. The problem with this is United Healthcare has many different plan types with differing coverages among them. This document also references a "Prosthetics / Orthotics Network" without ever clarifying what this is.
This document also says:
"Prostheses/orthotic devices that meet the individual’s functional needs are paid in full when obtained from a participating provider."
That is vague and does not answer your question.
One other possibility is the beneficiary may be able to access this information. While United Healthcare does have multiple plan types, it appears that Empire beneficiaries may be able to access their United Healthcare benefits here: https://www.empireplanproviders.com/myuhc.htm
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC