These are the responses I received to my inquiry about what to do if a
bilateral K-1 amputee, who having had been a successful K-3 unilateral
ambulator in the past was fitted with K-3 feet and the payment was denied b=
y
Medicare.
I am very much thankful to all who responded. It was a big help.
The records must document the patient’s current functional capabilities an=
d
his/her expected functional potential, including an explanation for the
difference, if that is the case. The DMERC recognizes within the functional
classification hierarchy that bilateral amputees often cannot be strictly
bound by functional level classifications.
Your patient is covered by the grandfather clause. Since he had a Seattle
foot on one side, Medicare cannot lower is functional level due to the
contralateral amputation. Need to appeal and you should win with the
supplier manual.
Did you list him as a K3 or K4 when billing for the energy storing foot? I=
f
you listed him as a K1 or K2 it would be denied even if bilateral or even i=
f
he was successfully using them in the past. Remeber that in order to bill
for and get paid for an energy foot, he needs to be listed as a K3 or K4.
You may want to consider him as a K4 simply because as a bilateral, his
needs and energy requiements are significantly higher than those of a
unilateral amputee.
I am not aware of any Medicare regulation that exempts bilateral amputees
from functional level classification. Medical Review Policy for Lower limb
Prostheses (L11453) does address the bilateral amputee and states the
following in pertinent part:
“The DMERC recognizes within the functional classification hierarchy that
bilateral amputees often cannot be strictly bound by functional level
classifications.”
To the best of my knowledge that is the only reference to bilateral amputee=
s
and functional level classifications. I think you have a good argument and =
I
would encourage you to pursue the matter through the review process.
I had a similar situation a year ago with an AK/BK patient that I used an
SNS knee with. I filed a review which was denied and then a request for a
hearing. I was assign a hearing officer and was requested by the hearing
officer to do a telephone “on record hearing” where the decision was “fully
favorable”. From my copy of the hearing officer decision: “This letter
contains my fully favorable decision on your Medicare B Hearing…(ISSUE) I=
f
the services in question are denied under =A71862(a)(1) of the Social Secur=
ity
Act, does waiver of liability apply pursuant to =A71879 of the
Act?…(Decision) After careful consideration of the record, I have
determined that Medicare benefits are warranted under the provisions of
=A71834(h) and =A71861(s)(8) of the Social Security Act. The Carrier previo=
usly
denied the services as “not medically necessary” under =A71862(a) (1) of th=
e
Act. As a result of my decision =A71862(a) (1) does not apply, therefore
waiver of liability under =A71879 is not an issue.”
In other words you are correct, but you have to prove it to Medicare. The
date of service was 06042004 and the EOMB is dated 12142004. I was very
concerned that I did not have a “detailed” prescription, just a “make this
man walk” type. I do not remember if Medicare even asked for the order. If
you would like, I should be able to copy most documents and fax them to you
if you think it would help.
I ran into the same issue with a patient of mine. I ended up talking with
AOPA who sent me the page. It was in the Aetna/Medicare manual which
described the K-levels. I found the link. Hope this helps.
With regard for the exception of the bilateral amputee, the following was
found at http://www.cignamedicare.com/dmerc/LMRP_LCD/LLP.html
Stephan R. Manucharian, CP
Orthopedic Arts
Brooklyn, NY 11201
718-858-2400; Fax: 718-858-9258;
[email protected]
