What is an insurance company looking for in a pre-determination request?  This is the provider's best chance of obtaining approval, so it is important to include  adequate information the first time around.  Here is a basic breakdown of the vital elements required to submit for a pre-determination of a prosthetic device:

• Physician dictation.  This dictation is most helpful if the amputation is discussed thoroughly in the notes, along with the patient's normal activities, the condition of the current prosthesis, and any specific problems that the amputee may be having. 
• Physician Prescription.  Most amputees will present a prescription at the initial appointment.  Though this prescription is often very general and is not adequate documentation alone, it is one more piece of the puzzle that should be submitted to the insurance company.
• Physician Certificate of Medical Necessity.  This is essentially a detailed prescription that includes all components of the prosthesis as well as an explanation of medical necessity.  Justification for prosthetic replacement should be detailed, yet clear.  For example, a socket replacement required due to extreme volume increase of the residual limb. 
• Cost Breakdown & List of Codes.  The insurance company will need to know the actual HCPCS codes involved and it's best to include a narrative explanation of each code, along with the charge and the insurance contracted allowable.
• Clinical Information.  This is the provider's opportunity to present a case with ample clinical information and clear justification for the need of the item.  It is wise to submit as much clinical information as possible, even photographs and measurement sheets.
• Manufacturer Invoices.  This is not always required, but is definitely necessary if the proposed device has not been assigned an established HCPCS codes.  Unlisted procedures will also require a breakdown of the labor associated with this device and what is in involved in the fabrication.

Assuming a favorable decision is received, the work doesn't stop there.  If the device is an 'unlisted procedure', be prepared for additional medical review once the actual claim is received by the insurance company.  There is still a possibility that, despite a pre-determination of approval, the claim could deny once submitted.  That is perhaps the most frustrating part about the pre-determination process.  Most pre-determination review protocols allow for a level or two of appeals; however, new information must be submitted at every level of appeal.  It's wise to keep a couple of cards up the sleeve in case this becomes necessary.  In other words, submit photographs first.  If that doesn't work, send video footage next time.