The profession is buzzing with talk of the proposed Medicare Lower Limb Prostheses (LLP) Local Coverage Determination (LCD). The last time Medicare moved to change this LCD (nearly ten years ago), the negative feedback from the O&P profession and the beneficiary community forced them to retire the adaptations. Medicare’s most recent draft revision of the LCD shows fewer and more targeted changes. How will these changes impact beneficiaries and O&P clinicians?
The proposed changes are a direct result of an LCD Reconsideration Ottobock submitted to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs). An LCD Reconsideration is a formal process anyone can initiate to request a change to a Medicare LCD. However, CMS strongly recommends that any requested change submitted through the formal LCD Reconsideration process be supported by credible research, clinical trials, and/or published medical journals. (Ottobock’s LCD Reconsideration request can be viewed in its entirety on the CMS website within their Medicare Coverage Database as an attachment to the proposed LLP LCD.)
Before the proposed LLP LCD can be finalized, the DME MACs are required to hear comments from the profession and beneficiary communities concerning the changes. An open public meeting took place February 22 and included a review of the changes and an opportunity for stakeholders to share comments and provide written feedback. Based on this commentary, the DME MACs may choose to make additional changes to the proposed LCD or decline further changes and publish the LCD as is. Additionally, they may choose not to move forward with any changes to the LCD at all, in which case the current, active LLP LCD would remain in effect.
The LCD Reconsideration submitted by Ottobock and the language of the proposed LLP LCD seeks to broaden the coverage of microprocessor knee componentry to beneficiaries who are classified as K2 functional level ambulators. In the current LLP LCD, microprocessor knee componentry is only covered for people at a K3 level and above. Nonetheless, many beneficiaries categorized as K2 level ambulators would functionally benefit from microprocessor knee technology. These proposed changes outline detailed coverage criteria, in addition to the basic coverage criteria, that must be supported in the medical records for payment to be considered.
It is expected that the changes would be positively received and adopted by the O&P community because it will broaden coverage, instead of limiting it. In public comment, there was concern expressed about the proposed coverage criteria requiring clinicians to rule out (trial and document) all other knee-shin systems prior to making the selection. Although Medicare may not enforce this criterion in a literal sense, other payers may choose to adopt this language into their own medical policies and require it.
Regardless of opinion about the proposed language, it is evident that Medicare is willing to adapt the current LLP LCD to benefit patients. In the future, we expect to see more favorable changes by Medicare in recognition of new technology and for improved beneficiary access to care the Medicare program.
Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are partners at O&P Insight. O&P Insight is a consulting and billing company specializing in the O&P industry. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can reach them at [email protected] or [email protected]. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.
Author’s note: As of the date this article was written, nothing had been published by the DME MACs regarding the finalization of the Proposed LLP LCD.