Separately Chargeable Prosthesis and Appliance List
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1 14 APRIL 2018 Separately Chargeable Prosthesis and Appliance List The Separately Chargeable Prosthesis and Appliance List contains all such prostheses and appliances that are eligible for funding by Bupa and may be charged separately by providers. This list may change from time to time. Use of a prosthesis or appliance must be related to an eligible condition/procedure. Please use this list in line with your current Bupa contract. Where mandatory is indicated please call Bupa Provider Services on Lines are open 8am to 6pm, Monday to Friday and 8am to 1pm on Saturday. Calls may be recorded and may be monitored. Bupa code Body AA215 HEAD AND NECK EYE ACRYLIC LENS AA180 HEAD AND NECK EYE CORNEAL GRAFT/DONOR MATERIAL ELIGIBLE FOR CORNEAL SURGERY AA227 HEAD AND NECK EYE ARTIFICIAL EYE PROSTHESIS ELIGIBLE FOR ONE PROSTHESIS PER EYE AB321 HEAD AND NECK BRAIN BRAIN STENT AA945 HEAD AND NECK BRAIN CEREBROVASCULAR SHUNT AA175 HEAD AND NECK JAW/MAXILLA TEMPORO MANDIBULAR JOINT AB308 HEAD AND NECK JAW/MAXILLA OBTURATOR ELIGIBLE FOR FIRST TEMPORARY AND FIRST PERMANENT OBTURATOR AA144 HEAD AND NECK JAW/MAXILLA BITE RAISING APPLIANCE NOT ELIGIBLE FOR FUNDING
2 Body AA177 HEAD AND NECK TEETH ENDOSSEOUS IMPLANTS AA921 HEAD AND NECK TEETH SUBPERIOSTEAL IMPLANTS AA922 HEAD AND NECK TEETH TRANSOSSEOUS IMPLANTS AA191 HEAD AND NECK EAR GROMMETS ELIGIBLE FOR ACUTE CONDITION (OTITIS MEDIA) AA176 HEAD AND NECK EAR COCHLEAR IMPLANTS ELIGIBLE WHERE DEAFNESS IS THE RESULT OF AN ACUTE ILLNESS OR INJURY AA469 HEAD AND NECK WIGS ELIGIBLE WHEN RELATED TO CANCER TREATMENT AB311 HEART HEART CARDIOVERTER DEFIBRILLATOR ELIGIBILITY CRITERIA DEPENDENT UPON COMPLETION OF CARDIAC DEVICE FORM AA169 HEART HEART SINGLE CHAMBER PACEMAKER AA923 HEART HEART DUAL CHAMBER PACEMAKER AA169 HEART HEART BIVENTRIBULAR PACEMAKER ELIGIBILITY CRITERIA DEPENDENT UPON COMPLETION OF CARDIAC DEVICE FORM AA170 HEART HEART HEART VALVE : REAL TISSUE AA226 HEART HEART HEART VALVE : SYNTHETIC TISSUE AB309 HEART HEART CARDIAC STENT AA644 HEART HEART DISPOSABLE HEART PUMP
3 Body AB324 HEART HEART MEDTRONIC REVEAL MONITORING SYSTEM DEVICE ELIGIBLE FOR THE DIAGNOSIS OF UNEXPLAINED FAINTING, DIZZY SPELLS, PALPITATIONS OR UNEXPLAINED CONVULSIONS AA181 HEART HEART MOBIN UDDIN I.V.C FILTER AB315 HEART HEART VASCULAR STENT AA198 BLOOD VESSELS BLOOD VESSELS WOVEN AORTIC ARCH AA171 BLOOD VESSELS BLOOD VESSELS DARDIK BIOGRAFT (VEIN BIOGRAFT) AA649 LIGAMENTS LIGAMENTS CRUCIATE LIGAMENT PROSTHESIS OF REPAIR OF CRUCIATE LIGAMENT AA195 LIGAMENTS LIGAMENTS PROSTHETIC LIGAMENTS AA924 LUNGS LUNGS IMPLANTABLE GAS EXCHANGE DEVICE (ARTIFICIAL LUNG) AB304 BREAST BREAST BREAST PROSTHESIS AA165 BREAST BREAST TISSUE EXPANDERS AA190 BREAST BREAST BECKERMENTOR TISSUE EXPANDERS AA163 BREAST BREAST POSTMASTECTOMY BRA RECONSTRUCTION SURGERY FOLLOWING MASTECTOMY. NOT ELIGIBLE WHEN USED AS PART OF COSMETIC ENLARGEMENT RECONSTRUCTION SURGERY FOLLOWING MASTECTOMY. NOT ELIGIBLE WHEN USED AS PART OF COSMETIC ENLARGEMENT RECONSTRUCTION SURGERY FOLLOWING MASTECTOMY. NOT ELIGIBLE WHEN USED AS PART OF COSMETIC ENLARGEMENT ELIGIBLE WHEN RELATED TO CANCER TREATMENT AA925 OESOPHAGUS OESOPHAGUS OESOPHAGEAL STENT ANTIREFLUX SURGERY AA172 OESOPHAGUS OESOPHAGUS ANGELCHICK PROSTHESIS OESOPHAGEAL SURGERY
4 Body AA199 SHOULDER SHOULDER TOTAL SHOULDER REPLACEMENT AA926 SHOULDER SHOULDER PARTIAL SHOULDER REPLACEMENT AA927 SHOULDER SHOULDER GRAFT JACKET MESH AA214 ELBOW ELBOW ELBOW PROSTHESIS AA194 WRIST WRIST DOW CORNING NOT ROUTINELY ELIGIBLE AA193 WRIST WRIST HOW MEDICA NOT ROUTINELY ELIGIBLE AA946 WRIST WRIST TOTAL WRIST REPLACEMENT NOT ROUTINELY ELIGIBLE AA928 HAND HAND SPLINT OF SURGERY TO CORRECT DUPUYTREN'S CONTRACTURE AA202 HAND HAND FINGER PROSTHESIS OF SURGERY TO THE FINGER AA947 SPINE SPINE ARTIFICIAL DISC REPLACEMENT ELIGIBLE FOR SINGLE LEVEL AND TWO LEVEL DISC REPLACEMENT AA929 SPINE SPINE INTERBODY SPACER (INCLUDING CAGE) AA930 SPINE SPINE INSTRUMENTED FUSION KIT AA931 SPINE SPINE INTERSPINOUS DISTRACTION DEVICE AA466 SPINE SPINE NU NEC PROSTHETIC CERVICAL DISC ELIGIBLE FOR SINGLE LEVEL AND TWO LEVEL DISC REPLACEMENT
5 Body AA465 SPINE SPINE GRANVIA DISC ELIGIBLE FOR SINGLE LEVEL AND TWO LEVEL DISC REPLACEMENT AA932 SPINE SPINE BONE GRAFT SUBSTITUTES AA933 SPINE SPINE KYPHOPLASTY KIT AA167 SPINE SPINE PRE/POST OPERATIVE PROSTHESIS FOR TREATMENT OF SCOLIOSIS AA183 SPINE SPINE MILWAUKEE BRACE AB327 SPINE SPINE SPINAL INSTRUMENTATION AA184 SPINE SPINE BOSTON BRACE AA185 SPINE SPINE BIVALVE POST OPERATIVE SPINAL HOLDING ORTHOSIS AA188 SPINE SPINE INFUSAID PUMP NOT ROUTINELY ELIGIBLE AA934 LIVER LIVER STENT/SHUNT AA935 KIDNEY KIDNEY URETERIC STENT AA228 BLADDER BLADDER ARTIFICIAL URINARY SPHINCTER AA203 BLADDER BLADDER ROSEN INFLATABLE INCONTINENCE PROSTHESIS AA212 BLADDER BLADDER KAUFMAN INCONTINENCE PROSTHESIS
6 Body AB312 BLADDER BLADDER GENITOURINARY STENT AA174 PENIS PENIS PENILE SPLINT INFLATABLE OF SURGERY FOR CANCER AA173 PENIS PENIS PENILE SPLINT SOLID OF SURGERY FOR CANCER AB256 PENIS PENIS IMPLANTATION OF INFLATABLE PROSTHESIS INTO PENIS OF SURGERY FOR CANCER AB328 UTERUS / VAGINA UTERUS / VAGINA INTRAUTERINE DEVICE/MIRENA COIL ELIGIBLE FOR THE MANAGEMENT OF ACUTE PHASES OF MENORRHAGIA AA201 SCROTUM SCROTUM TESTICULAR PROSTHESIS ELIGIBLE FOLLOWING CANCER SURGERY, SURGERY TO REMOVE UNDESCENDED TESTES OR TO TREAT TORSION OF THE TESTES AB318 STOMACH / ABDOMEN STOMACH / ABDOMEN GASTROINTESTINAL STENT AA939 PANCREAS PANCREAS PANCREATIC STENT AA182 HIP HIP HIP PROSTHESIS WITHOUT CEMENT AA186 HIP HIP HIP PROSTHESIS WITH CEMENT AA940 HIP HIP PARTIAL HIP REPLACEMENT AA658 KNEE KNEE KNEE BRACE(S) ELIGIBLE WHEN USED AS ESSENTIAL PART OF REPAIR OF CRUCIATE LIGAMENT AB307 KNEE KNEE DONJOY/ACL BRACE ELIGIBLE WHEN USED AS AN INTEGRAL PART OF THE RECOVERY PERIOD FOLLOWING CRUCIATE LIGAMENT REPAIR AA168 KNEE KNEE KNEE PROSTHESIS
7 Body AA941 KNEE KNEE PARTIAL KNEE REPLACEMENT AA942 KNEE KNEE AUTOLOGOUS CHONDROCYTE IMPLANT ELIGIBLE WITHIN TRIAL CRITERIA AA943 KNEE KNEE OSTOCHONDRIAL GRAFT AA192 KNEE KNEE DUOPATELLA KNEE PROSTHESIS AA197 KNEE KNEE INSALLBURNSTEIN KNEE PROSTHESIS AA200 KNEE KNEE NEW JERSEY TOTAL KNEE SYSTEM AA944 ANKLE ANKLE TOTAL ANKLE REPLACEMENT AA213 FOOT FOOT TOE PROSTHESIS AB329 FOOT FOOT PNEUMATIC WALKER BOOT ELIGIBLE WHEN USED INSTEAD OF SURGERY/PLASTER CAST FOLLOWING SURGERY
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