A Call to Action - Medicare Proposes Changes Detrimental to Prosthetic Coverage

Following is information every amputee, their families and friends need so we can notify our representatives.

If we don’t advocate for ourselves, who will?

Medicare recently published a “PROPOSED/DRAFT Local Coverage Determination (LCD): Lower Limb Prostheses (DL33787)” that, if approved, will have major negative impacts on all amputees nationwide.

While this initial determination addresses coverage for lower limb amputees, if approved there will surely be follow-on determinations on all prosthetics including upper limbs.

At this point you may be saying, “I don’t get Medicare. This does not relate to me.” Actually it does. The insurance companies take their lead from Medicare. While some plans may go beyond Medicare’s coverage, most adhere to the coverage amounts and physician, physical therapist and prosthetist documentation requirements.

While the changes are written in the form of procedural changes and billing / reimbursement changes that our Orthotists and Prosthetists must follow, they directly affect:

• Our requirements classifications, i.e. how active or mobile we are,
• Our ability to get new O&P devices,
• Repairs to existing ones and
• Related treatment from our O&P companies

Overview of Proposed Changes

Following is a basic list of key changes. Note: The following list is highly edited and is not the complete list. It can be quite confusing.

Following this write-up is information about a briefing session you can attend.

• The changes creates clear definitions and distinctions between different prosthesis supplied: immediate, preparatory, and definitive.
• Definitions for what components and features are “medically necessary” has been highly restricted.
• Add-on changes to a new prosthesis will either be denied or not medically necessary – clearly this will adversely impact patient care.
• Our Prosthetists will not be allowed to bill for any additions, adjustments, modifications, replacements for the first 90 days after the prosthesis is delivered. This may affect their ongoing viability.
• For those getting their first prosthesis, the proposed policy does not allow for socket changes or component changes on preparatory prostheses for the first 90 days.
• The policy requires an in-person medical evaluation with the ordering physician or a licensed certified medical professional.
• The draft limits the use of custom fabricated socket inserts and requires additional justification.
• Suction suspension systems will be considered not medically necessary for functional level 1 patients.
• A consolidation of the billing codes O&P practitioners use will severely impact the patient’s choice of prosthetic feet and ankles that best meet their individual clinical needs - arbitrarily translating into lower quality care for Medicare amputees, and so lesser mobility and reduced independence.
• Draft policy does not provide coverage for amputees that did not participate in a rehabilitation program immediately following their amputation but are now candidates for prosthetic intervention.
• The requirement that the prosthesis must provide the patient with “the appearance of a natural gait” should not preclude coverage of a prosthesis that is otherwise functional.
• Justification requirement changes include the elimination of patient potential from the revised functional level categories and may significantly limit access to higher functional level componentry for patients who are progressing.
• If the patient’s records show that any form of mobility aid (cane, crutches, walker, etc.) access to higher quality prosthetic components will be severely limited.
• The draft further reinforces service limiting documentation policies that must be followed by our Prosthetists and places burdensome requirements on our physicians.

The American Orthotic & Prosthetic Association (AOPA) is a national trade association for O&P professionals. It is coordinating actions of both for industry professionals and patients like ourselves.

AOPA has done three major things:

1. They are coordinating efforts for O&P practitioners to provide comments.
2. They have developed a summary for patients so they may understand how these proposals would impact their care; http://mobilitysaves.org/2015/07/proposed-medicare-lower-limb-prosthesis-policy-will-significantly-limit-your-access-to-clinically-appropriate-and-medically-necessary-prosthetic-care/
3. They have created a website to make it easier for interested parties to respond to the proposal. http://aopavotes.channeldemocracy.com/connect/write?alert=1965

Note: The Deadline For Comments Is The Close Of Business - August 31, 2015.

Those wishing to write directly can submit comments electronically to the DME MAC medical director at the following e-mail address - DMAC_Draft_LCD_Comments@anthem.com

What We Can and Must Do

This a time for all amputees to mobilize. We need to understand the changes and build a campaign of everyone we know affected by these changes to respond.

This includes all amputees, their families, friends, doctors, physical therapists, and Prosthetists. Do not assume everyone that supports medically is aware of these proposed changes.

If you know people in other states, call them too.

How do I learn more about the changes and how they will affect me?

Amy Mehary, the head of M-Power has agreed to provide a briefing to everyone interested.

Here Are Additional Steps We Can Follow:

1. Log on to AOPA’s website and comment. By filling in your name and address the website will insert who your letter should go to. In my case it is Representative Pete Sessions, Senator Ted Cruz and Senator John Cornyn.
2. Notify everyone - families, friends, doctors, physical therapists, and Prosthetists. Ask them to respond.
3. If you know any of our legislators contact them directly. If they will be in town before the August 31st comment deadline see if you can arrange a meeting with them and Dallas Amputee Network. They will respond to a large group of voters.
4. Sign the We The People Petition created to put this issue in front of the Obama Administration.

For additional information contact Amy Mehary amehary@mpowerprosthetics.com.