Hello Everyone,
I received several replies to my previous question about Prosthetic Leg vs.
Power Mobility Devices (Scooters, wheelchairs, etc).
Nobody provided exact information or any exact, 100% for sure, or provided
any links to documentation regarding this topic. There is nothing I can
find that will directly address this situation about an amputee who needs a
power mobility device, but also needs a prosthetic leg (or 2).
The comments ALL stated that they think that Medicare will NOT pay for a
prosthetic leg IF the patient has recently received a Power Mobility Device.
One person commented that it is reasonable that IF the patient has received
a PMD recently, but the patient has since then recovered and improved
dramatically, THEN the patient should be able to have the “Face to Face”
exam with a physician, also documentation from a Physical Therapist with the
Amputee Mobility Predictor evaluation, showing that this patient has
improved and can indeed walk and the prosthetic leg will enhance the quality
of life. WITH this documentation on file, Medicare should pay for a
prosthetic leg.
My thoughts on this are that there will for sure be a denial and to be
prepared for a long drawn out audit, and then an appeal. It makes sense
that this will prove medical necessity, but getting through the hoops and
hurdles will be lengthy.
In this situation, I now know for SURE that this patient was indeed lying to
my, straight to my face, saying that she did NOT get a scooter or power
chair. She said that she had thought about getting one, but when she found
out that she either must choose between the prosthetic leg and a scooter,
she decided to NOT get the scooter.
I would have trusted her, and never checked the Medicare website for “Same
or Similar” using the K0800, or K0834 codes (there are several codes for
power chairs, you should check them ALL for your patients to make sure they
are being honest), BUT in the doctor’s notes I saw a paragraph where the
doctor stated something about her being afraid of the new scooter, it was
top heavy and she was afraid of falling over in it. The physical therapist
also documented something about her new scooter.
When I asked her about it, she still said that she did not have a scooter,
and I asked her why the physician documented something like that. She then
was upset that the doctor wrote anything about this, or that I found out
that she had this scooter.
She told me something about “the other place” where she had been going told
her to find another clinic to go to and deny anything about any power
mobility device. She said that if I made her the leg, she would get the leg
to keep, and I would not get paid. And I guess she has NO sense of honesty,
no sense of feeling bad about doing financial damage to a business, or to
another individual. We all know how much a K-3 level knee and foot cost.
We all know how much liners cost, and also the cost of the 2 check sockets
and laminating a final socket. THOUSANDS!!! And she was ok with trying to
basically steal this from me.
The worst part is that during this time period, I have been diagnosed with a
pretty bad illness. Ok, more than just “pretty bad”, it is about as bad as
it could have been. The doctor diagnosed me with Stage 4, metastatic
squamous cell carcinoma, lung cancer, which had spread to the liver, lymph
system, many places in the bones, and also the brain. Originally the
prognosis was anywhere from 6-8 months. This patient KNOWS this condition,
she and her daughter were in my office and in tears over this, saying they
are praying for me. BUT even with this kind of compassion, she is knowingly
trying to lie to me to get this leg at MY expense.
As for the cancer…… yes, it is devastating news as you can imagine. I
am only 51, very healthy. My son (age 14) and I do everything together. We
ski during the winter. We enjoy riding mountain bikes, running in local 5K
races, etc. I have NEVER smoked, NEVER lived with anyone who smokes. I
cannot stand or even tolerate tobacco anything. So being diagnosed with
lung cancer is really a shock.
I have been tested for the genetic things, and found out that I do have the
BRCA 1 and BRCA 2 genes, which are the breast cancer genes. In males, this
increases the chance for having prostate cancer, pancreatic cancer,
lymphoma, and lung cancer.
The biopsy of the tumor and also of my blood showed that I have the EGFR
mutation, and also ALK 1 mutation. MD Anderson has NEVER seen a patient
with both of these mutations at the same time, in the same cancer. (Leave
it to me to be the first and to change everything about this mutation
stuff…they have actually done several biopsies now to just check and make
sure that there was no error in the testing because this is so rare to ever
see). But with the EGFR mutation, there are several Targeted Immunotherapy
drugs that work to kill this cancer. I am taking one called Tarceva which
has worked miraculously in me. The original tumor was the size of an
orange, and in just 8 weeks, the 2nd PET CT Scan and MRI showed that this
tumor was TOTALLY gone! There were dozens of metastatic sites on March 7,
and then on May 13 there were only 3 small sites left that were active with
cancer. I have had another round of scans and MRI’s done in August, and the
cancer is dying even more. The prognosis today is excellent. Of course
none of us have any guarantee on how long we will live, but being diagnosed
with something like this really is a huge wake up call. I thought I would
live to be over 100, that is in my genes. Three of my grandparents lived
almost to 100, and one made it to 101. My great aunts and uncles also lived
up to 104. But this really now changes things. With the drugs that are
available to treat this mutation, I should really be able to live
potentially as long as anyone else now, but the thoughts of making it to 100
are pretty small now I think.
Another thing that crossed my mind is about the environment where we all
work, with carbon dust on everything, breathing the fumes of the resins and
other chemicals. I have a pretty good dust collector and system, but still
I KNOW that I have breathed in a lot of this stuff over the past 18 years.
I asked the doctor about this, he said that squamous cell carcinoma is ONLY
related to tobacco products, 98% of patients use this. But there are 2% who
will get this who are like me. He highly doubts that this has anything to
do with the working environment. THEN with the genetic history, with the
BRCA genes present in my body, that explains this much more.
Anyway, back to the Power Mobility Devices…..
Finally, I was able to now log into the CGS website, mycgsportal . com ,
where I could put in her medicare information and check for sure what she
has. And sure enough, she DID get a scooter, a couple days before
Christmas.
I HIGHLY encourage EVERYONE to check the Medicare website or portals that
are online and available to use. Check EVERY patient for same or similar
items. You can see if they have been anywhere else to get another
prosthetic limb and are lying to you about not having a new leg for many
years….. OR you can find out if they have a power mobility device, which
will basically get the claim denied for any prosthetic leg.
In order to get qualified or “pre-determination” to get a PMD, the patient
must be classified and documented that the patient has NO ability to
ambulate. Also, their upper body strength must be so bad or weak so they
cannot propel a regular wheelchair or device. With those conditions being
met, THEN the patient will qualify for the PMD.
In order to get the basic K-1 level prosthetic leg, it must be documented
that the patient can at least stand, and transfer independently, and also
they must have the desire to ambulate, and the ability to walk at a fixed
cadence on level surfaces. For a K-1, the patient MUST BE ABLE to walk at
least at a single speed. I guess if they have the “potential” even to walk,
that could be argued, BUT it clearly states in the process for determination
of the PMD that the patient has no potential to ambulate, and has no ability
either. I would assume that if the patient has resigned themselves to using
a PMD, then the desire to ambulate has pretty much also gone. These 2
different descriptions for a patient make it totally impossible to qualify
for both, unless something has changed along the way and the patient has
gotten much better and can walk… OR if the patient had the prosthetic leg
first, and THEN something got worse and they needed a PMD.
Thanks everyone,
Jim DeWees, CP
