Hello colleagues, Here are the responses I got to my questions about
Empire BCBS, L5645, and their “prosthetic consultant” that reviews
prosthetic pre-authorization requests. Thanks so much to everyone that
responded; I really appreciate it.
*My Original Post:*
Over the last ten months or so we have found that, as far as Empire BCBS
and Empire Medicare Advantage goes, that L5645 is under attack — their
position is that if the amputee has a gel liner, that a flexible inner
socket/rigid frame design is “duplicative in function”. Basically they
assert that just a prosthetic sock is sufficient as an interface if L5645
(flexible inner socket) is to be used, and if L5673 (gel liners) is used,
then the flexible inner socket is unnecessary. I have been over every
inch of the LCD and Empire’s Clinical UM Guideline, and neither of them say
anything about L5645 not being able to be used as part of the same
prosthesis that includes L5673. I have appealed these L5645 denials
numerous times, and have both won and lost essentially identical cases at
the First-Level Appeal stage, at the Maximus Reconsideration stage, and at
the ALJ stage. I just don’t get it. Sometimes we win, sometimes we lose,
at any given stage, and it seems like there is no actual policy or line of
reasoning that Empire can give as to why these codes are being denied.
This is even when the physician provides rock-solid notes that explain what
the gel liner will do for the patient, what the flexible inner socket will
do for the patient, and why these items do not serve the exact same purpose
and are not duplicative in function. Which brings me to my questions:
1. Have any of you been experiencing this same problem?
2. I have heard from some folks in the field (but I have been unable to
confirm) that Empire and a number of other insurers use Performant Recovery
(yes, that Performant Recovery) as a “prosthetics consultant” to do
prosthetic authorizations review. Do any of you have knowledge of or proof
of this?
3. I have also heard from some folks in the field (but I also have been
unable to confirm) that the primary architect of the Draft LCD works for
Performant Recovery and that essentially, this person is using Draft LCD
criteria — because the infamous Draft LCD actually does specify that the
gel liners and flexible inner sockets are basically duplicative in function
— to judge the medical necessity of prosthetic preauthorizations. This is
happening even though the Draft LCD is not in force and they are supposed
to used the existing, in-force LCD as coverage criteria, presumably because
the claims reviewer crafted the Draft LCD and believes in it fervently. Same
thing here, do any of you have knowledge of or proof of this?
4. Have any of you had more consistent success in appealing denied L5645
codes with Empire BCBS Medicare Advantage?
Thanks so much for your time and assistance with this! I really appreciate
it. I’d be happy to post a summary of responses.
——————————————————–
So here are the responses I got… most of them kind of land “around” the
questions I posed and don’t really answer them directly, but some of you
have had similar experiences as my office has been having. Others
discussed issues regarding the use of L5645 — some felt it is unnecessary
for certain types of prostheses and that the code is overused, and others
disagreed. Here are the responses:
> I received a denial from Humana Medicare Advantage for the exact same
> reason & just submitted my Level 2 Appeal. The letter from Humana stated
> that the claim was reviewed by “an experienced certified
> prosthetist/orthotist”.
>
> https://urldefense.proofpoint.com/v2/url?u=http-3A__www.aopanet.org_wp-2Dcontent_uploads_2015_09_lcd-2Ddraft.pdf&d=DwIFaQ&c=pZJPUDQ3SB9JplYbifm4nt2lEVG5pWx2KikqINpWlZM&r=pVyaAUHOR6gxxThvjGI9X7hrz_ONYByMAadML4fTENI&m=GCIy0FnkBqXKqHQdPNXpX3dzwFQHBUwtq_07DYaLvFY&s=d4iPrnjKJNWeNP_6s0-c2MjEQOdjPvo3APw5zmkJfpc&e= …
> All insurance companies are suppose to follow the Medicare guidelines. Good
> Luck!
>
> Yes, this has happened to us here in Washington as well, not sure what
> insurance it was though. Eventually, we won the appeal but we were denied
> twice.
>
> We have had Performant recovery do a review for Fidelis and we are trying
> to appeal for cross codes which thet did not initialy have in their system
> when Medicare made it effective.
>
> So far Empire isn’t in WA yet and I’ve not had that denial yet. It is
> truly disgusting that insurance companies don’t even bother to visit our
> offices to see what we do. Have you talked to your state insurance
> commission? What they are doing may be illegal. Isn’t it nice that AOPA
> is nowhere to be seen.
>
> Are you documenting where you are cutting reliefs for boney prominences or
> muscular expansion to decrease pressure or allow for muscles to contract
> and not create abnormal rotation?
> Just a thought.
> Just wondering if these denials are transtibial? Thought being some
> large companies use the flexible inner on TTs routinely & I had done
> reviews years ago where ‘they’ touted need for L5645 in TTs for cushioning
> the limb. Never were there windows cut out for bony prominences or
> mention of issues with gel liner & laminated sockets only as their
> rationale. So, in fact, this is duplication of services & simply padding
> the bill. OR they are very poor practitioners who cannot make a
> comfortable OR do not take the time to make a comfortable laminated socket.
> Some added the justification for using flexible inners in TT sockets for
> “adjustability”. Again, pads can be added inside a laminated socket in a
> clean & efficient manner to take up volume or adjust socket shape to an
> atrophying limb w/o stuffing the pads between flexible inner socket &
> laminated outer.
> If these denials relate to TF sockets then there IS an issue.
> But again, IF you’re not cutting out a window for less pelvic obliquity
> in sitting or lowering your laminated trim lines sufficiently to allow for
> “brim comfort” then what’s the purpose? The TF sockets I see here from
> that same company with routine TT flexible inners leave the laminated trims
> 1/2″ from flexible inner trims…. does nothing for comfort & they Never
> cut a window. So, these full length flexible inner sockets are just
> adding bulk & weight to an already thickly laminated, heavy socket!? Padding
> the bill.
> I think this is another example of ‘up coding’ or ‘using every angle to
> make buck’ by certain folks that is ruining things for the rest of us.
I’m curious… I have two additional justifications for the flexible inner
> liner. Prior to listing those, I would reference Jaegers’ 1995 article that
> found that following amputation, resected muscles naturally experience
> 40-60% sarcopenia (permanent muscle atrophy). I would also state that the
> structure of the lower leg is highly asymmetrical with regard to muscle
> location. That is, a majority of the muscle is located in the posterior
> region and a majority of the bone is located in the anterior region.
>
> –Weight bearing will naturally change soft tissue, but will not change
> bone.
> –The patient will never reduce the volume by sitting and waiting, even if
> you gave it years…
> –This 40-60% percent change is natural, unavoidable, and occurs within a
> rigid socket that prevents identification of problem areas of atrophy.
> –If the problem is left unaddressed, it results in two things: skin
> breakdowns on the amputated side and compensatory excessive loading of the
> sound limb. This is a primary reason why 50% of leg amputees lose the sound
> leg within 2-3 years.
> –Prosthetic socks are uniform in nature, unlike the localized areas of
> atrophy. Thus, they function as a stopgap and are incapable of resolving
> the sarcopenia.
>
> The flexible inner liner is the only component that can perform 2 critical
> functions that prevent escalation of issues that may naturally result in
> additional amputations:
> The flexible inner liner is indispensable to the clinician for accurately
> diagnosing areas of sarcopenia on the residual limb. The liner may be
> removed from the socket and positioned onto the presented limb (with
> silicone liner properly donned). Unlike a durable rigid carbon socket, the
> clinician may accurately palpate on the flexible inner liner both the
> location and magnitude of atrophy by compressing manually. Otherwise,
> troubleshooting during this critical time is done blindly.
The flexible inner liner can be manipulated by the patient such that
> atrophy pads may be inserted with ease. At delivery of a prosthesis, a
> patient is provided with various pads that may be inserted between the
> liner and the socket by the patient at home to ameliorate discomfort caused
> by atrophy. These pads may be numbered and may be provided in various
> thicknesses.
> Thus, both the patient and the practitioner rely on the flexible inner
> liner to effectively ensure proper fit and extend the functional useful
> life of the prosthesis as well as help to prevent additional medical
> expenses that may result from additional amputations. Hope that helps!
Thanks again to all who responded!
William Lifford, CP Progressive O&P, Inc., 1111 Willis Avenue,
Albertson, NY 11784 516-338-8585
