The publication of the Medicare draft LCD and Policy Article for Lower Limb Prostheses obviously caused great concern within the O&P community as evidenced by the huge show of support during the August 26th public meeting and rally at DHHS headquarters.  A consistent question that has been heard since the release of the policy is: How long will it take to see the affects of this policy trickle down into the private insurance market.  The answer to that question, unfortunately, is not long at all.

In its most recent medical policy bulletin published in August of 2015 and effective for dates of service on or after October 1, 2015, United Healthcare, currently the largest insurer in the United States, issued a policy statement that states, “The use of vacuum pumps for residual limb volume management and moisture evacuation systems among amputees is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer-reviewed medical literature”.  A remarkably similar statement in the Medicare draft LCD and Policy Article states that claims for HCPCS codes L5781 and L5782 which describe vacuum based residual limb volume management and moisture evacuation systems will be denied as not medically necessary because there is “insufficient published clinical evidence to support these claims.”  While I try to never be pessimistic about things, the timing of this policy decision by United Healthcare, along with the similar language that appears in both policies forces me to question the genesis of the United Healthcare coverage decision.

During its meeting with high ranking CMS and HHS officials on the afternoon of August 26th, AOPA expressed its deep concern that while the policy published by Medicare was done so as a draft, with no bearing on current claims for lower limb prostheses, private insurers would be quick to use language in the draft to justify policy decisions regarding coverage of lower limb prostheses.  Unfortunately, It appears that AOPA’s concern was well founded.

AOPA has provided CMS and HHS with a copy of the recent United Healthcare policy bulletin to drive home the point that the language from the draft LCD and Policy Article is already being picked up by private insurers, and has also reached out to United Healthcare directly to discuss this policy decision.  As this issue progresses, AOPA will provide updates regarding the future coverage of vacuum based volume management and moisture evacuation systems by Medicare and private payers.

The decision by United Healthcare to declare vacuum based volume management and moisture evacuation systems will not be the last decision that is based on language in the Medicare draft LCD and Policy Article.  It is important that you review any policy bulletins you receive that appear to limit coverage of prosthetic services and notify AOPA immediately so we may address these issues promptly.

AOPA’s Take.  Where you go…..When you need to know!!!

Last Wednesday, I experienced one of my proudest moments as an employee of AOPA and a member of the O&P community. I witnessed the full power of the amputee community as they stood up and proclaimed enough is enough and demanded recognition as folks who, despite their missing limbs, must be treated fairly by the government and the Medicare program.

Wednesday morning began with the scheduled public meeting to provide input on the draft Local Coverage Determination (LCD) and Policy Article governing Medicare coverage of lower limb prostheses that was published simultaneously by the four DME MACs on July 16, 2015.  As those of you that are familiar with the draft LCD and Policy Article are aware, the proposed policy would severely limit access to clinically appropriate and medically necessary lower limb prostheses for Medicare beneficiaries.  I was honored to sit in the room with more than 400 people and 80 speakers who felt the need to express their concern over the potential ramifications of the draft policy on Medicare beneficiaries and amputees covered by private insurance.  While the draft policy is a Medicare only policy, many private insurers adopt Medicare policy as their own, greatly expanding the universe of amputees potentially affected by the proposed policy changes.  Speaker after speaker took the podium to discuss their very personal stories and express their grave concern regarding how the proposed policy may restrict their access to quality prosthetic care.  To say these stories were emotionally moving is an understatement.  The bravery and willingness to share very personal issues in order to influence the direction of the proposed policy was simply awe inspiring.

After the public meeting, more than 150 individuals boarded buses for a trip to Washington, DC to participate in a rally in front of the Department of Health and Human Services building.  Amputees and non-amputees joined together and made sure their voices were heard for almost 3 hours as they marched, rallied, gave speeches, and literally stood on a soap box to deliver the message to CMS that artificial limbs are not a luxury.  Toward the end of the rally, representatives from AOPA, the O&P Alliance, and the Amputee Coalition met with CMS Acting Administrator Andrew Slavitt as well as other high ranking CMS and DHHS officials to reiterate the concerns of the O&P community regarding the potential impact of the draft LCD and Policy Article.  Reports from this meeting indicate that it was extremely positive and that CMS will be discussing the draft LCD and Policy Article further with its DME MAC contractors.

As the rally ended and the folks that had dedicated their personal time and money to participate in the days events headed home, I took a moment to reflect on the day.  Never in my twenty years in the O&P industry have I seen such a coordinated effort of the amputee community, the O&P community, and the groups that represent them, to make sure their voices were heard.  I can truly say that on Wednesday, August 26, 2015, I have never been prouder to work for and be part of the O&P community.

AOPA’s Take.  Where You Go….When You Need to Know!