Upper-limb Luxuries, the Deluxe Item

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Another hurdle to approval, Miguelez says, is the introduction of new technologies in upper-limb components that do not have an L-Code. "We find that most insurance carriers don't have an accurate understanding of what these components can do for the patient and frequently label them as luxuries when the reality is that they simply improve function."

O'Brien concurs. "In general, the coverage policies that pertain to upper-extremity prosthetics are much less developed than for lower extremity."

O'Brien says a prime example is that Medicare still does not have a coverage policy specific to upper-limb prosthetics. "The same basic coverage criteria from the Lower Limb Prostheses LCD can reasonably be applied to establishing coverage and medical necessity for upper-limb interventions," he says. "However, without a clear policy to refer to, clinicians are left with much more exposure to potential reimbursement battles."

Stephanie Morgan Greene, compliance officer for Ottobock Patient Care and acting compliance officer at Ability Prosthetics & Orthotics, Exton, Pennsylvania, says the process of obtaining approval for an upper-limb prosthesis is harder due to a convergence of factors. First, the chances of having to use a miscellaneous/not otherwise covered code for an upper limb is greater. Second, Medicare does not have an upper-limb policy, and most commercial insurance companies also lack similar policies. Third, it is common for a person with an upper-limb amputation to need two prostheses, a body-powered prosthesis and a microprocessor device, to be able to complete all his or her daily functional needs. "Insurance companies simply do not understand the reasoning behind the request for two prostheses," Greene says. "They have a lack of understanding of the needs and treatment options for upper-extremity amputees. We are fighting an uphill battle at times to educate the reviewer on how the upper-extremity prosthesis works and benefits the patients."

It is not uncommon, Greene says, for commercial payers to call an upper-limb prosthesis a "deluxe" or "convenience" item.

Nothing, however, could be further from the truth, Greene says. "As a patient once told me, the only deluxe option would be the return of her own hand."

Read more about reimbursement challenges and tips for overcoming them in "Trials and Turbulations of Insurance Approval" in the August issue.