<img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2008-05_04/4-1.jpg" hspace="4" vspace="4" /> <b>On the surface, the five-year policy</b> on the full replacement of most orthotic devices promulgated by Medicare is clear-cut and understandable to the profession. What isn't working is Medicare's policy on denying what it deems similar items months and even years after the service is provided. While the policy may have been instituted as a cost-saving maneuver to conserve Medicare's limited funds, it is having quite the opposite effect. Apparently there wasn't enough input allowed from practicing COs to advise the committee that created this policy about the harmful effects this would have on Medicare recipients and O&P providers, as well as the increased Medicare personnel required to deal with the appeal process. The problem manifests itself in several ways. The first issue is that the patients aren't aware that the five-year rule exists. I've never met a patient who realized that the orthosis he or she was about to receive is supposed to last for five years because that patient read about it in Medicare's regulations. The second issue arises from patient belief patterns. While it's understandable that permanently disabled patients expect their orthoses to last, patients who are convinced by their orthopedist that the orthosis prescribed for the treatment of their condition, such as a long bone fracture or herniated disc, will be needed as a short-term rehabilitation device want to believe that the treatment and rehabilitation process has affected a "cure" in their condition. They are anxious to discard their orthosis as a bad memory of a bad injury. These patients believe that it won't happen again and easily dispose of or misplace their orthoses. The third issue is hygiene. Some orthoses such as Sarmiento Style Fracture Braces and some postoperative spinal orthoses are meant to be worn 24/7 for several months. These orthoses are a breeding ground for bacteria due to the layers of dead skin, body oils, and perspiration that have accumulated during the healing process. Expecting these devices to be reused if there is a reoccurrence of the condition such as an osteo infection, removal of surgical hardware, or a herniated disc occurring at another level in the spine is not a well-thought-out plan by Medicare. The biggest problem seems to be scaling down from a TLSO to a lesser, more flexible orthosis or scaling up from an LSO to a more rigid TLSO for greater immobilization. It's common protocol for orthopedic spine specialists to try and take a conservative approach with new patients complaining about spinal maladies such as stenosis, sciatica, and spondylitis to treat them with medications and mild- to moderate-control spinal orthoses. If the condition worsens within the next five years, which is highly likely when you are dealing with septuagenarians and octogenarians, we must inform these patients that a custom TLSO or LSO that might circumvent surgery may not be covered because they have already received what Medicare might consider a similar device. We also must tell them that we might not know for months about the outcome because Medicare's similar device list isn't published anywhere. Medicare also expects us to tell fixed-income patients that they must sign an Advance Beneficiary Notice (ABN) to receive a $1,500 custom orthosis that won't be covered because they received a $350 L/S brace four years ago. I've seen a number of fixed-income patients opt not to get the orthotic service and use their resources to procure covered medications to deal with the pain or seek out Medicare-covered physical therapy treatments. Some go so far as to request hospitalization because it is covered. Where is the economic sense in that plan? Medicare adopted the L-Code system so that it could differentiate the variety of orthoses that are available to meet the patient's needs as prescribed by the patient's physician. Medicare did not adopt the entire list of L-Codes that were available because it knew that there were some similarities, so it picked those that were decidedly different from one another. Now when a patient needs an LSO, the patient is denied because he or she had received a TLSO within the last five years and visa versa. The system is flawed. It's creating a hardship for the patient and transferring the expenses from one Medicare pocket to another. <i>Michael Mangino, CPO, LPO, CPed, is president of the Bay Orthopedic and Rehabilitation Supply Company, which has multiple offices throughout New York State. He is also president of Prosthetics and Orthotics Management Associates Corporation (POMAC), a member of the American Orthotic & Prosthetic Association (AOPA), the American Academy of Orthotists and Prosthetists (the Academy), and the New York State chapter of the Academy.</i>
