On July 18, the Centers for Medicare & Medicaid Services (CMS) and the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) medical directors released the much-anticipated final Local Coverage Determination (LCD), Lower Limb Prostheses (L-33787). They also published an updated Lower Limb Prostheses – Policy Article that offers additional details on the new coverage including significant new examples and details on beneficiaries who qualify as K2 and K3 ambulators. In fact, there are examples offered that should help prescribers and practitioners identify more accurately which beneficiaries should be assigned a particular functional level. Notably, the DME MAC medical directors posted on their respective websites a response to the commenters who submitted statements earlier this year on the draft LCD. These comments, taken as a whole, are very supportive of the expertise necessary to provide prosthetic care and the clinical prosthetists who perform these services.
The final LCD expands the coverage criteria for microprocessor-controlled prosthetic knees (MPKs)—including fluid and pneumatic knees—for Medicare Functional Classification Level-2 (MFCL-2) beneficiaries (commonly known as K2), who are considered limited community ambulators and require a prosthetic knee based on the best available evidence. The LCD states that MPKs may be a viable therapeutic option for some limited community ambulating Medicare beneficiaries with lower-limb amputations. Specifically, the final LCD states, “Therefore, the criteria in the Lower Limb Prostheses Local Coverage Determination will be expanded to allow coverage of fluid, pneumatic, or electronic/microprocessor control additions for prosthetic knees in MFCL-2 beneficiaries when supporting documentation in the medical record outlines the rationale for selection of the higher-level knee.” The effective date for this final LCD was September 1.
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