I received only one constructive and a very comprehensive response to the
following post:
Dear list,
Does anybody know whether Medicare has a regulation in respect to allowed
frequency of prosthetic services? Yes, I know all the correct phrases about
medical necessity and physical changes etc., but what I am interested to find
out is if Medicare anywhere mentions a specific time period. I hear it is 5
years in some regions. Could anyone direct me to either Medicare web-site or
any other literature with that info.
******************Response**************
> Section 428 of the Benefits Improvement and Protection Act (BIPA)
> addresses Medicare coverage for replacement of prosthetic devices
> and parts and references a 3 year useful lifetime rule. It addressses
prosthetics
> only and in Region D, a 5 year useful lifetime rule continues to be in
place
> for orthotics.
>
> That does not mean Medicare will not pay if replacement is necessary
> prior to the 3 or 5 year time frame. Region D routinely requests
> supporting documenation and will pay the claim when provided such.
> The following supporting documenation is supplied when requested:
> 1. Physician Order
> 2. Delivery Acceptance Form
> 3. Clinical records of physician or orthotist/prosthetist.
>
> Our organization has very few problems in establishing medical necessity
> for replacemnt prior to the 3 or 5 year time frame.
>
> DHHS/HCFA(now CMS) transmittal AB-01_06 clarifies the issue of
> prosthetic replacements as addressed in BIPA 2000. The act actually added
a
> provision to the Social Security Act. The new provision is 1834
(h)(l)(G)(i).
> The date of this transmittal was January 18, 2001.
Stephan R. Manucharian, CP *
Orthopedic Arts *
Brooklyn Heights, New York*
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