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.
