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Anthem Covering Lower-limb Microprocessor Prostheses

by The O&P EDGE
June 1, 2021
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Effective May 20, Anthem Blue Cross announced coverage of microprocessor-controlled lower-limb prostheses and foot-ankle prostheses when medical necessity is documented. The announcement listed the devices as “including, but not limited to, knee prostheses (such as the Otto-Bock C-Leg device, the Genium Bionic Prosthetic System, the Genium X2 and X3 devices, the Össur Rheo Knee, and the Endolite Intelligent Prosthesis) and foot-ankle prostheses (such as the Proprio Foot, the PowerFoot BiOM, and the Endolite élan foot)” when the following criteria is documented in the medical records:

•        Patient has adequate cardiovascular reserve to master higher level technology

•        Patient has cognitive ability to learn about the technology

•        K3 or above functional level

•        There is a reasonable likelihood of better mobility or stability using the microprocessor-controlled ankle/foot than is with the use of a mechanical foot

•        The medical documentation regularly ambulates in situations where the device will provide benefit (e.g., ascend/descend stairs, traverse uneven surfaces or walk long distances)

The above criteria must be documented in the patient’s medical record along with any assessment results and/or corroborating documentation from other healthcare practitioners.

Össur noted that other large payers consider microprocessor-controlled ankle/feet to be medically necessary under same or similar conditions. This policy change was also adopted by the following health plans as of May 1, according to Össur:

•      Amerigroup Real Solutions

•      Anthem

•      BCBS Georgia

•      BCBS Minnesota

•      BlueChoice HealthPlan of South Carolina

•      Community Connect Health Plan

•      Empire BCBS

•      Healthlink

•      Simply Healthcare

•      Unicare

In 2018, Anthem was sued by two of its insureds for denying all requests for microprocessor-controlled foot-ankle prostheses.

To read the policy, visit Anthem’s Medical Policies & Clinical UM Guidelines page.

 

Related posts:

  1. Microprocessor Tech: Still Driving Change
  2. If “Spring Is King,” Why Does a Prosthetic Foot That Absorbs More and Returns Less Energy Allow Users to Walk Faster?
  3. The Dawn of Powered Lower-limb Prostheses
  4. Microprocessor-Controlled Knees: Evolution of a Game Changer
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