Proposed changes to lower limb policy 'race to bottom'

BALTIMORE - Proposed changes to coverage requirements for prostheses could severely limit the number of patients who could gain the greatest mobility, say O&P stakeholders.

“There are a fair number of leaps that are made that don't have any scientific backing,” said Tom Fise, executive director of the American Orthotics and Prosthetics Association. “We think a lot of people are going to be asking, 'Why would Medicare want to do this?'”

The four DME MACs released the draft local coverage determinations for lower limb prosthetics July 16.

Among the proposed changes: requiring a face-to-face visit; and requiring the patient to complete a rehab program before they can obtain a prosthetic device.

While neither requirement is inappropriate, says Fise, they both will delay prosthetic care.

“The mechanism they've set forth for the evaluation doesn't involve a simple office visit,” he said. “The physician may see a patient, or refer the patient to a certified medical professional who would evaluate the patient on a vast number of expanded criteria. That report goes back to physician who then can agree with the report or bring the patient back for another visit.”

Requiring rehab will eliminate those patients who, following an amputation, aren't willing to go through it at that time, says Fise.

The proposed changes would also impact the class of prosthetic a patient can receive. A patient whose Medicare record shows they have used an assistive device, or have any cardiac or pulmonary issues, would not qualify for a K3 device. (K1 devices are for those least able to regain mobility and K4 devices are for those most able).

“If you have a cane, maybe you use it at night to go to the bathroom, you aren't eligible,” said Fise.

The proposal also seeks to consolidate many of the codes into one code without any clarification of reimbursement, he said. That will result in a one-size-fits-all model instead of devices being tailored to the patient.

“This could be a race to the bottom in terms of quality,” said Fise. “The only explanation I can give is that it is an effort to drive down expenditures at all costs.”

Comments are being accepted through Aug. 31. AOPA has a created a comment portal for interested parties to submit comments for possible inclusion into the association's comments.