2015 Draft LCD Causing Current Denials

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By William Lifford, CP

You may have recently seen a sudden uptick in denials for L-5645 (flexible inner socket with rigid outer frame). Most of the practitioners I know have been flooded with them of late. The denials say that L-5645 is considered duplicative of L-5673 (socket insert).

There seem to be two opinions about the need for flexible inner sockets. The first camp, of which I am a member, believes that they are beneficial to people with transtibial amputations for reasons such as muscle changes during gait, socket brim comfort, the ability to fenestrate the socket and relieve bony prominences, and instances where the locking mechanism might not be in line with the rest of the prosthesis (such as with the Fillauer lock). I don't believe that flexible inner sockets preclude the use of a gel liner (socket insert). The other camp maintains that a flexible inner socket is never needed when using a gel liner, and that many prosthetists use the code simply to maximize their billing.

I checked the LCD, the Coverage Determination Guidelines, and clinical medical policies or utilization management guidelines of the major insurers, and found no basis for the denial of L-5645. Fidelis, UnitedHealthcare, and Empire BCBS all began denying L-5645 seemingly at the same time. I discovered that these companies share a prosthetics consultant from an audit/recovery/review company who seems to believe that L-5645 is an easily deniable code—a code that is not likely to be specifically supported in the medical record so it will have a high success rate of denial and generate thousands of dollars in saved insurance company dollars.

I also found that this denial stems from the wording in the 2015 Draft LCD that was never in force and has been retired. Remember how everyone feared that the Draft LCD's draconian wording was going to set the tone for other insurers? That's exactly what has happened. The Draft LCD says that flexible inner sockets cannot be part of the same prosthesis as gel socket inserts because they are duplicative in nature. As it turns out, the prosthetics consultant triggering the denials was instrumental in designing and writing the Draft LCD.

The in-force LCD states, "One (1) socket per individual definitive prosthesis may be considered medically necessary when the prosthesis meets above criteria." L-5645 is a type of socket, so this statement applies. But the LCD further states, "No more than two of the same socket inserts (L-5654-L-5665, L-5673, L-5679, L-5681, L-5683) are allowed per individual prosthesis at the same time." L-5645 is not listed.

Practitioners and administrative staff must fight this absurdity. My office has successfully fought these denials by making sure the physician clearly documents why the flexible inner socket is necessary, why the gel socket inserts are necessary, and how the two items are not the same, not duplicative in function, and while they both help make a prosthesis more comfortable for the amputee, they are not the same item.

It is a burden to make sure everything is documented this specifically, but it must be done if you want to provide a flexible inner socket as part of a patient's prosthesis. Don't hesitate to go to bat for your patients.

 

William Lifford, CP, is a practitioner at Progressive O&P, Albertson, New York. He can be reached at william.lifford@gmail.com.