Proposed Medicare Lower Limb Prosthesis Policy Will Significantly Limit Your Access to Clinically Appropriate and Medically Necessary Prosthetic Care
The contractors for Medicare have released a proposed revision to Medicare’s lower limb prosthetic policy. Some of these changes would create unreasonable and clinically inappropriate hurdles to your ability to receive quality prosthetic limbs that best meet your specific clinical needs without delay. Key issues are outlined below, and if you share these concerns, it may be time to take action to make sure that you maintain access to the highest quality prosthetic care available.
The proposed policy could limit your access to clinically appropriate prosthetic care through the following provisions:
New amputees will be restricted to use of a basic “preparatory” prosthesis while participating in a post amputation rehabilitation program. The use of technologically advanced prosthetic components will not be permitted during this preparatory phase, forcing active amputees to utilize a prosthesis that does not meet their clinical needs. New amputees will only be eligible for a “definitive” prosthesis after successful completion of a rehabilitation program using a basic prosthesis.
New amputees will be required to have an extensive, in person, evaluation performed by their treating physician or a designated Licensed/Certified Medical Professional (LCMP) prior to the delivery of their definitive (long term) prosthesis. Additionally, before you can receive an appropriate prosthesis, a health professional would be required to certify to Medicare that you have sufficient cognitive, cardio-pulmonary, and neuro-muscular ability to ambulate with the prosthesis that was prescribed for you. The requirement for this extensive evaluation, including documentation of conditions that may have no impact on the patient’s ability to effectively use a prosthesis, will cause significant delays in the delivery of clinically appropriate prostheses.
Medicare will no longer allow the potential for enhanced mobility/functional ability of patients to be considered when determining what type of prosthesis best meets their clinical need. In order to qualify for technologically advanced prosthetics, patients must be able to demonstrate their mobility/functional capabilities now, in real time, as opposed to how they can benefit from advanced technology to improve their mobility in the future.
If you utilize, or if your records show that Medicare has paid for, any form of mobility aid (cane, crutches, walker, etc.) your access to higher quality prosthetic components will be severely limited, regardless of your functional capabilities. This is arbitrary and discriminatory, especially for bilateral amputees who may require an assistive device for balance purposes only.
If you cannot achieve what Medicare contractors deem a “natural gait” while wearing a prosthesis you may not be eligible to receive one. This is another discriminatory action that will severely limit access to clinically appropriate prostheses.
Roll-on style prosthetic liners will only be covered for patients who cannot be fit with basic socket inserts. The restriction of Medicare coverage for what has become the primary method of socket suspension as well as creating a protective interface between the residual limb and socket may result in poor clinical outcomes for patients forced to rely on outdated socket interface technology.
Choice of prosthetic feet will be limited by a consolidation of high technology prosthetic foot procedure codes into a single, generic, prosthetic foot code that describes all dynamic response feet—What’s available will likely be driven more by price and less by the technology or features of the prosthetic foot that uniquely enhance your mobility.
Medicare will no longer cover volume management/moisture evacuation systems that are used to ensure the proper fit of the prosthesis. Coverage of these systems is especially important for amputees who experience significant volume changes in their residua l limb throughout the day.
The clinical knowledge and expertise of your prosthetist will no longer be considered relevant in the decision as to what type of prosthesis will best meet your specific clinical needs. A the prosthetist is considered a “supplier with a vested interest in payment of a claim” they may play no role in documenting the medical necessity for the specific type of prosthesis that best meets your clinical needs.
These issues only represent the major changes that are being proposed as part of the revised policy for Medicare coverage of Lower Limb Prostheses.
AOPA needs your help to ensure that you continue to have proper access to the best quality prosthetic care under the Medicare program. Please click here to quickly send comments to the contractors.
You can also email your customized comments by August 31st directly to the Medicare contractors at DMAC_Draft_LCD_Comments@anthem.com. Make sure to reference LCD Draft: Lower Limb Policy.