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Advocacy Action Center: Stop Implementation of the Problematic Lower Limb Prostheses LCD

Aug 25, 2016

The four Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare Administrative Contractors (MACs) have all issued an identical draft Local Coverage Determination (LCD) on the subject of Lower Limb Prostheses. Since all four are issuing the same LCD, that means it will be applicable in all states and territories across the nation. The physiatry specialty is primarily focused on diagnosing and serving the needs of people with a wide range of disabilities and chronic conditions, including limb amputations. If implemented as is, the proposed LCD would adversely affect Medicare beneficiaries' access to needed lower limb prostheses. 

Your Academy has drafted a comment letter to be sent on behalf of AAPM&R, however, we strongly encourage every physiatrist to send a message to CMS and the DME Contractors to reconsider and change many of the elements within this proposed LCD. Implementing the draft LCD without doing so has the potential to harm patients in need of prostheses, and will not comport with the standard of care. Please take a moment to send a comment letter using the customizable draft template linked below, if you wish.

If you would prefer not to send your letter through Voter Voice, comments may be submitted by mail or e-mail to:
 
Stacey Brennan, M.D.

National Government Services
8115 Knue Rd
Indianapolis, Indiana 46250-
DMAC_Draft_LCD_Comments@anthem.com

All comment letters are due by August 31, 2015.


Template Letter

 

Stacey V. Brennan, M.D., FAAFP

Medical Director, DME MAC, Jurisdiction B

National Government Services 8115 Knue Rd.

Indianapolis, IN 46250-1936

DMAC_Draft_LCD_Comments@anthem.com

 

Dear Dr. Brennan,

I write this letter today as a physiatrist, a physician specialist that is board certified in Physical Medicine and Rehabilitation. Our specialty is primarily focused on diagnosing and serving the needs of people with a wide range of disabilities and chronic conditions, including limb amputations. With appropriate rehabilitation, many patients can regain significant function, live independently, and enjoy fulfilling lives. In light of this, I am writing in reference to the draft LCD referenced above, which is being put forward by the four Medicare DME contractors regarding lower limb prostheses. If implemented as is, I believe this LCD would adversely affect Medicare beneficiaries' access to needed lower limb prostheses.

I am very concerned that the draft LCD is not in line with the current standard of prosthetic care, nor does it cite any evidence in support of the determinations made in it. The proposed modifications essentially rewrite the current LCD without acknowledgement of advances that have been made in the design and use of prosthetic limbs. The need for a prosthetic limb seems pretty straight forward - you must have a missing limb and be able to use a prosthetic in place of the missing limb. Yet the proposed LCD contains a long set of requirements that a patient must satisfy before being eligible to receive prosthetic care. These requirements include upper body strength, adequate posture, cognitive capability, sufficient neuromuscular control, sufficient cardio-vascular capacity, and the functional ability to ambulate for differing distances and in differing environments. While consideration of this medical information is reasonable, I fear that the proposed LCD may be interpreted by DME MACs or other reviewers in such a way as to disqualify amputees for coverage of more advanced levels of prosthetic care, or any prosthetic care at all. Since the parameters are not defined, the prescribing physician may be of the opinion that a patient has, for example, sufficient cardio-vascular capacity, but a reviewer may not agree, and thus deny coverage for the appropriate prosthesis.

The face to face medical exam is a good requirement, but I question the usefulness of providing for an LCMP to complete all or part of the exam. The physician must see the patient regardless of whether he or she is also seen by an LCMP, and must essentially repeat the exam in order to sign off in agreement with the LCMP. In addition, an LCMP is not necessarily qualified to do a complete medical examination; it would be beyond the scope of practice for a physical therapist or occupational therapist. Did you mean to say, perhaps, that an LCMP can do the functional assessment portion of the exam? If yes, and the LCMP is qualified to do a functional assessment, why does a physician who has chosen to delegate the functional assessment to an LCMP also need to do his or her own functional assessment in order to determine agreement? 

Another issue is that the proposed LCD downplays the importance of a certified prosthetist in determining functional status and prosthetic requirements. While your concern for stopping fraud and abuse is laudable, the prohibition on including a prosthetist's notes as part of the evidence for medical necessity does not seem to address the issues identified in the OIG audits of 2011 and 2012. It would seem to be fairer to legitimate prosthetists, as well as more effective in combatting fraud, to instead require the process to include elements recommended by the OIG. Some suggestions might include requiring the prosthetist to be licensed if the state provides licensing, and certified by one of the two main certifying bodies in those states that don't license prosthetists, and requiring the physician to indicate that he or she has reviewed the prosthetist's notes in light of his or her own examination and agrees with the recommendations.  

The proposed LCD's requirement for prosthetic candidates to undergo a course of rehabilitation before being eligible for a definitive prosthesis is unreasonable. Perhaps a functional assessment using a preparatory prosthesis would be beneficial, but a full course in rehabilitation should take place with the definitive prosthesis. Also, the proposed LCD should specifically state that the assessment with the preparatory prosthesis should consider the patient's functional potential when he has his definitive prosthesis, not just his performance with the preparatory prosthesis. Consideration of a patient's potential is one of the most fundamental characteristics of rehabilitation.  Since the definitive prosthetic may be significantly more sophisticated and better matched to the patient than the preparatory prosthetic, it would be inaccurate and unjust to base the assessment only on what the patient can do with the preparatory prosthesis.

The requirements for beneficiaries to be able to walk with a "natural gait" and/or without an assistive device in order to be eligible for more advanced forms of prostheses is also without merit.  It is irrelevant if the patient needs an assistive device or walks with a limp so long as he or she is able to achieve the highest function of which they are capable.

I strongly urge CMS / the DME Contractors to reconsider and change many of the elements within this proposed LCD. Implementing the draft LCD without doing so has the potential to harm patients in need of prostheses, and will not comport with the standard of care.