No.S-11011/25/2014/CGHS-(P)
Sub: Revision of lists and rates of artificial appliances for CGHS / CS(MA) beneficiaries and general guidelines for eligibility criteria therefor.
ANNEXURE-IA
Sl. No. | Name of Prosthesis | Approved Rate/Price |
1. | Transtibial prosthesis (Below Knee Prosthesis) (Its components include-S.S. Pylon/tube, SACH FOOT, Foot Adapter , Bonded Pylon/Pylon with 4 screw Adaptor, Tube Clamp Adaptor, Socket Adaptor, Sleeve Suspension, Foam Cover, Covering Socks, Socket charges, etc.) | Rs.20,000/- |
2. | Transtibial Prosthesis (Below Knee Prosthesis) with silicone / PU liner | Rs. 37000/- |
2.a | Transtibial Prosthesis (Below Knee Prosthesis) with silicone / PU liner with shuttle lock mechanism | Rs.45500/- |
3. | Symes Prosthesis Its component includes- SYME’S FOOT, Foot Adapter Sleeve Suspension, Socket Mounting Adaptor, Covering Socks Socket charges, etc. | Rs.19300/- |
4. | Partial Foot Prosthesis ( Shoe with filler) | Rs.7000/- |
5. | Trans Femoral Prosthesis ( Above Knee Prosthesis) (Its components include-S.S. Pylon/tube, SACH FOOT, Foot Adapter, Bonded Pylon / Pylon with 4 screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs. 40840/- |
6. | Trans Femoral Prosthesis ( Above Knee Prosthesis) with Suction Valve | Rs.40840 + 3800=44640/- |
7. | Trans Femoral Prosthesis ( Above Knee Prosthesis) with Silicon/ PU liner | Rs.61140/- |
7.a | Trans Femoral Prosthesis ( Above Knee Prosthesis) with Silicon /PU liner with shuttle lock mechanism | Rs. 69640/- |
8. | Knee Disarticulation Prosthesis (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs. 51940/- |
9. | Hip Disarticulation Prosthesis (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Single axis Prosthetic Knee Joint, Hip Joint (basic), Tube (Angle tube adaptor, 10 degree) Short Tube, Socket Adaptor, Foam cover, Covering Socks, Socket fabrication & fitment charges.) | Rs.60300/- |
ANNEXURE-IB
Sl. No. | Name of Prosthesis | Approved rate/Price (Child 7-12 years) | Approved rate/Price (Child 0-6 years) |
1. | Transtibial prosthesis (Below Knee Prosthesis) (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor, Tube Clamp Adaptor, Socket Adaptor, Sleeve Suspension, Foam cover, Covering Socks, Socket charges, etc.) | Rs.18,140/- | Rs.5000/- |
2. | Trans Tibial Prosthesis (Below Knee Prosthesis) with silicone / PU liner | Rs. 35,140/- | Not applicable |
2.a | Trans Tibial Prosthesis with silicone / PU liner with shuttle lock mechanism | Rs. 35140+ 8500 =43640 | Not Applicable |
3. | Symes Prosthesis Its component includes- SYME,S FOOT , Foot Adapter Sleeve Suspension,Socket mounting adaptor, Covering Socks Socket charges | Rs.19300/- | Rs.5000/- |
4. | PARTIAL FOOT PROSTHESIS (Shoe with filler) | Rs.4000/- | Rs.1500/- |
5. | Trans Femoral Prosthesis ( Above Knee Prosthesis) (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic KneeJoint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs. 49,980/- | Rs.12000/- |
6. | Trans Femoral Prosthesis ( Above Knee Prosthesis) with Suction Valve | Rs.49980 + 3800=53,780/- | Not Applicable |
7. | Trans Femoral Prosthesis (Above Knee Prosthesis) with Silicon / PU liner | Rs.70,280/- | Not Applicable |
7.a. | Trans Femoral Prosthesis ( Above Knee Prosthesis) with Silicon/PU liner with shuttle lock mechanism | Rs. 70280+ 8500=78780 | Not Applicable |
8. | Knee Disarticulation Prosthesis (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic Knee Joint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs. 49,980/- | Rs.12000/- |
9. | Hip Disarticulation Prosthesis (Its components include-S.S. Pylon/ tube, SACH FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Single axis Prosthetic Knee Joint, Hip Joint (basic), Tube (Angle tube adaptor, 10 degree) Short Tube, Socket Adaptor, Foam cover, Covering Socks, Socket fabrication & fitment charges.) | Rs.60300/- | Rs.15000/- |
NOTE:
1. Prescription of Trans Tibial Prosthesis may be considered as Below Knee Prosthesis.
2. Prescription of Trans Femoral Prosthesis may be considered as Above Knee Prosthesis.
ANNEXURE-IC
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7- 12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Transtibial prosthesis (Below Knee Prosthesis) (Its components include- S.S. Pylon/ tube, DYNAMIC RESPONSE FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor, Tube Clamp Adaptor, Socket Adaptor, Sleeve Suspension, Foam cover, Covering Socks, Socket charges, etc.) | Rs.26,700/- | Not Applicable | Not Applicable |
2. | Trans tibial Prosthesis (Below Knee Prosthesis) with silicone / PU liner | Rs.43700/- | Not Applicable | Not Applicable |
3. | Trans tibial Prosthesis (Below Knee Prosthesis) with silicone / PU liner with shuttle lock mechanism | Rs.52200 | Not Applicable | Not Applicable |
4. | Trans Femoral Prosthesis (Above Knee Prosthesis) (Its components include- S.S. Pylon/ tube, DYNAMIC FOOT, Foot Adapter, Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic Knee Joint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs. 47,540/- | Not Applicable | Not Applicable |
5. | Trans Femoral Prosthesis (Above Knee Prosthesis) with Suction Valve | Rs.47540 + 3800=51,340/- | Not Applicable | Not Applicable |
6. | Trans Femoral Prosthesis (Above Knee Prosthesis) with Silicon / PU liner | Rs.64,540/- | Not Applicable | Not Applicable |
7 | Trans Femoral Prosthesis (Above Knee Prosthesis) with Silicon / PU liner with shuttle lock mechanism | 64540+ 8500=73040/- | Not Applicable | Not Applicable |
8. | Knee Disarticulation Prosthesis (Its components include- S.S. Pylon/ tube, DYNAMIC FOOT, Foot Adapter , Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint, Socket Adaptor ,TES Belt, Foam cover, Covering Socks, Socket fabrication & fitment charges) | Rs.58640/- | Not Applicable | Not Applicable |
9. | PARTIAL FOOT PROSTHESIS | |||
9a. | Shoe filler with carbon plate | Rs.9000/- | Rs.5000/- | Rs.3000/- |
9b. | GREAT TOE SILICON PROSTHESIS | Rs.9000/- | Rs.5000/- | Rs.3000/- |
9c. | Silicone Prosthesis For Second Toe to Vth Toe | Rs.7500/-each | Rs.4000/- | Not Applicable |
RECOMMENDED CRITERIA FOR HIGH END PROSTHESIS
1. Dynamic foot can be prescribed only for Military, paramilitary, commando persons / police personals sustaining amputation in saddle and likely go back to active and strenuous work.
2. Dynamic foot can also be prescribed for young / children and dynamic athletes of University, cultural activities, State/ National or international level.
3. Shoe filler with carbon plate can be prescribed only for Military, paramilitary, commando persons / police personals sustaining amputation in saddle and likely go back to active and strenuous work.
4. Shoe filler with carbon plate can also be prescribed for young / children and dynamic athletes of University, Participating in cultural activities, at State / National or international level.
5. In case of Bilateral Upper Limb amputation, Externally Powered Prosthesis /Myoelectric Prosthesis may be prescribed for one side and body powered Prosthesis or Passive Prosthesis for the other side.
ANNEXURE-ID
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7-12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Trans Radial or Below Elbow / Wrist Disarticulation Passive Prosthesis | Rs.10,000/- | Rs.5000/- | Rs.2000/- |
2. | Body Powered Prosthesis (Trans Radial or Below Elbow / Wrist Disarticulation) Its components includes trans radial kit and socket | 17000/- | 12000/- | Not Applicable |
3. | Trans Humeralor Above Elbow / Elbow Disarticulation Passive Prosthesis | Rs.20,000/- | Rs.10,000/- | Rs.5,000/- |
4. | Body Powered Prosthesis (Trans Humeral or Above Elbow / Elbow Disarticulation) | 28000/- | 22000/- | Not Applicable |
5. | Shoulder Disarticulation Passive Prosthesis | Rs.30,000/- | Rs.20,000/- | Rs.10,000/- |
6. | Shoulder Disarticulation body powered Prosthesis | Rs. 37,000/- | 28000/- | Not Applicable |
ANNEXURE-IE
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7- 12 Years) | Approved rate/Price CHILD (0-6) Years |
1. | Externally Powered below elbow or Trans radial / Wrist Disarticulation prosthesis (It includes:- Hand, Lithium ion Battery (one pair) with cover, Electrodes, Wrist Unit Battery Charger & Transformer, Electrode cable, Connector block cable Silicone Glove, Flexible inner Liner and socket, etc) | Rs.1,29,500/- | Not Applicable | Not Applicable |
2. | Externally Powered Trans Humeral / Elbow Disarticulation Prosthesis (It includes:- Hand, Lithium ion Battery (one pair) with cover, Electrodes, Wrist Unit, Mechanical Elbow, Battery Charger & Transformer, Electrode cable, Connector block cable Silicone Glove, Flexible inner Liner and sockets, etc) | Rs.1,76,500/- | Not Applicable | Not Applicable |
3. | Silicone Finger Prosthesis each | Rs.7000/- | Rs.5000/- | Not Applicable |
4. | Silicone Thumb Prosthesis | Rs.8000/- | Rs.6000/- | Not Applicable |
5. | Silicone Partial Hand Prosthesis | Rs.35000/- | Rs.25000/- | Rs.10,000/- |
ANNEXURE-IIA
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7- 12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Soft / Semi rigid Cervical Collar | 200/- | 200/- | Not Applicable |
2. | Philadelphia or Two post Cervical collar / Head Cervical Orthosis (Moulded collar) | 1500/- | 1500/- | 1200/- |
3. | Soft L.S. corset / Belt | 700/- | 500/- | Not Applicable |
4. | SOMI BRACE / Three Post Cervical Orthosis | 2000/- | 2000/- | Not Applicable |
5. | Four Post Cervical Orthosis | 1200/- | 1000/- | 800/- |
6. | Rigid L.S.O / Chair Back Orthosis | 1200/- | 1000/- | Not Applicable |
7. | Rigid TLSO / Taylor,s brace, Knight Taylor,s brace, William,s brace | 1500/- | 1200/- | 1000/- |
8. | Hyperextension brace / ASH / CASH / JEWETT BRACE | 1200/- | 1000/- | Not Applicable |
9. | CTLSO ( MILWAUKEE BRACE) | 5000/- | 5000/- | Not Applicable |
10. | Head Cervical Thoraco Orthosis (HCTO) | 1500 | 1500/- | 1200/- |
11. | TLSO BI- Valve / Body Jacket | 3000/- | 3000/- | 2500/- |
12 | UNDER ARM BRACE (Boston Brace / Miami Brace / Wilmington Brace / NYOH Brace ) | 3500/- | 3500/- | Not Applicable |
13. | HALO BRACE | 15000/- | Not Applicable | Not Applicable |
Abbreviations:
1. L.S.O— Lumbo Sacral Orthosis
2. ASH- Anterior Spinal Hyperextension Brace
3. CASH– Cruciform Anterior Spinal Hyperextension
4. TLSO—- Thoraco Lumbo Sacral Orthosis
5. CTLSO—– Cervical Thoraco Lumbo Sacral Orthosis
ANNEXURE-IIB
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7-12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Soft Heel Pad / M.T. Pad with Insole ( One Piece) | 200/- | 200/- | Not Applicable |
2. | Arch Support (Unilateral) | 300/- | 200/- | 200/- |
3. | Silicone / PU arch support (One Piece) | 350/- | 250/- | Not Applicable |
4. | Medial / Lateral Wedge | 100/- | 100/- | 100/- |
5. | Soft Insole cross link polymer (One Piece) | 100/- | 100/- | Not Applicable |
6. | Soft Insole ( Plastozote) One Piece | 300/- | 200/- | Not Applicable |
7. | Silicone / PU Insole (One Piece) | 500/- | Not Applicable | Not Applicable |
8. | Silicone Heel Cushion (One Piece) | 300/- | Not Applicable | Not Applicable |
9. | Molded / customized Insole (One Piece) | 600/- | 500/- | 400/- |
10. | Silicone Toe separator (One Piece) | 200/- | 100/- | Not Applicable |
11. | UCBL ( Unilateral) | 800/- | 600/- | 500/- |
12. | SMO without shoes (One Piece) | 1200/- | 1000/- | 800/- |
13 | Flat Feet / CTEV Shoes Pair (Leather) | 1200/- | 800/- | 700/- |
14. | Molded Shoe ( Leather)- one side normal & one side affected | 2200/- | 1600/- | Not Applicable |
15. | Molded Shoe ( Leather)- both side affected | 3000/- | 2000/- | Not Applicable |
16 | Shoe Raise | Rs. 50 per ½ inch | Rs. 50 per ½ inch | Not Applicable |
17. | Open toe shoes for paraplegic one pair | 1500/- | -Not Applicable | Not Applicable |
18. | D.B. Splint with / without shoe | Not Applicable | Not Applicable | 800/- |
19. | AFO Conventional (One Side) | 2500/- | 2000/- | 1500/- |
20. | AFO Conventional (Bilateral) | 3500/- | 2700/- | 2000/- |
21 | Polypropylene / Customized A.F.O without shoes | 1200/- | 1000/- | 800/- |
22. | FRO (Floor Reaction Orthosis) | 1800/- | Not Applicable | Not Applicable |
23. | Pneumatic walker | 3500/- | Not Applicable | Not Applicable |
24. | Knee Orthosis Polypropylene (Valgum /Varus, immobilizer etc.) | 1500/- | 1200/- | 900/- |
25. | P.T.B Brace without shoes | 1800/- | 1500/- | 1200/- |
26. | Knee Sleeve without hinge | 500/- | 500/- | Not Applicable |
27. | Knee Sleeve with hinge | 800/- | 800/- | Not Applicable |
28. | Off loader Knee Orthosis | 17000/- | Not Applicable | Not Applicable |
29. | KAFO conventional with shoe (One side) | 4000/- | 3200/- | 2000/- |
30. | Bilateral KAFO conventional with shoe | 5500/- | 4500/- | 4000/- |
31. | KAFO custom molded without shoe (One side) | 4000/- | 3200/- | 2000/- |
32. | Femoral Fracture Brace Non weight relieving | 1500/- | 1000/- | 800/- |
33. | Femoral Fracture Brace weight relieving | 4000/- | 3200/- | 2000/- |
34. | HKAFO Conventional with shoes (One side) | 5000/- | 4000/- | 3000/- |
35. | Bilateral HKAFO Conventional with shoes | 6500/- | 5500/- | 4500/- |
36. | HKAFO Polyproxyline custom moulded without shoes (One side) | 5000/- | 4000/- | 3000/- |
37. | Trilateral Orthosis | 4000/- | 3200/- | 2000/- |
38. | HIP Abduction Orthosis (Conventional) | Not Applicable | 1000/- | 1000/- |
39. | Pavlik Harness for CDH | Not Applicable | Not Applicable | 2500/- |
40. | Hip Bracing (Immobilizer) | 2000/- | 1500/- | Not Applicable |
41 | SWASH Brace | Not Applicable | 18000/- | 18000/- |
42 | Reciprocating Gait Orthosis | 32000/- | Not Applicable | Not Applicable |
ANNEXURE-IIC
Sl. No. | Name of Prosthesis | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7-12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Finger orthosis static ( One Piece) | 150/- | 100/- | 100/- |
2. | Finger orthosis dynamic ( One Piece) | 200/- | 100/- | 100/- |
3. | Hand Orthosis | 400/- | 300/- | 300/- |
4. | Thumb Spica / stabilizer | 300/- | 200/- | 200/- |
5. | Knuckle bender | 500/- | 350/- | Not Applicable |
6. | Wrist Hand Orthosis( Static) P.P | 700/- | 500/- | 400/- |
7. | Wrist Hand Orthosis (dynamic) | 1000/- | 700/- | 500/- |
8. | Elastic Wrist Hand Orthosis | 400/- | 300/- | 200/- |
9. | Tennis Elbow support | 200/- | 200/- | Not Applicable |
10. | Adjustable arm sling | 300/- | 300/- | Not Applicable |
11. | Elbow orthosis (static) | 900/- | 700/- | 500/- |
12. | Elbow orthosis (Dynamic) | 1000/- | 800/- | 600/- |
13. | Fracture Brace ( Below Elbow) | 1200/- | 800/- | 700/- |
14. | shoulder brace (Immobilizer) | 1000/- | 800/- | 700/- |
15. | Gun slinger shoulder orthosis | 1000/- | Not Applicable | Not Applicable |
16. | Humeral fracture brace without elbow hinge and forearm support | 1200/- | 800/- | 800/- |
17. | Humeral fracture brace with elbow hinge and forearm support | 1600/- | 1200/- | 1000/- |
18. | Shoulder Elbow Wrist Hand Orthosis ( Air plane splint) | 2200/- | 1600/- | 1400/- |
ANNEXURE-III
S.N0. | NAME OF ORTHOSIS | Approved Rate/Price (Above 12 years of age) | Approved Rate/Price CHILD (7- 12 Years) | Approved Rate/Price CHILD (0-6) Years |
1. | Walking Stick (Adjustable) Aluminium | 350/- | 350/- | Not Applicable |
2. | Tripod / Quadripod walking stick Aluminium | 750/- | Not Applicable | Not Applicable |
3. | Auxillary Crutch / Elbow crutch (Aluminum) Adjustable | 850/- | 650/- | Not Applicable |
4. | Walker/Rollator (Aluminium) | 1500/- | 1200/- | 900/- |
5. | C.P.Chair / C.P.Stand | Not applicable | 7300/- | 7000/- |
6. | Commode Chair | 2500/- | 2500/- | Not Applicable |
7. | Wheel Chair Folding( Chrome Plated) | 7000/- | 4000/- | Not Applicable |
8. | Motorized Wheel chair | |||
(i) Quadriplegic wheel chair with Chin and Head Control | 1,10,000/- | Not Applicable | Not Applicable | |
(ii) Quadriplegic wheel chair with joy stick | 60,000/- | Not Applicable | Not Applicable | |
(iii) Motorized wheel chair (Handle driven) | 35,000/- | Not Applicable | Not Applicable | |
9. | Tricycle Hand Propelled | 6000/- | Not Applicable | Not Applicable |
Source: http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File740.pdf
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COMMENTS
how to download Pdf of this OM
Sir, Doctor Mr.Anil Arora (Ortho Principal Professor Max hospital Patparganj Delhi) has advise/prescribed me a L.S.Belt for spine problems. Can it covered under cghs & permission for purchasing procedure. I am a (64 yrs old) retired cghs beneficiary
I want to know if cervical pillow is reimbursable at CGHS rate prescribed by CGHS doctor.