M E M O R A N D U M

To:All Interested Parties and Individuals

From:Peter W. Thomas, J.D.

Date:August 10, 2015

Re:Rescind Medicare’s New DraftLocal Coverage Determination for Lower Limb Prostheses

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On July 10, 2015, the four Durable Medical Equipment Medicare Administrative Contractors (“DME MACs”) released a proposed draft Local Coverage Determination (“LCD”) for Lower Limb Prostheses. The LCD can be found here:

An “LCD” is not legislation, nor is it a formal regulation. It is the Medicare program’s way of clarifying what benefits it will cover in a particular area of medicine and how they will pay for those benefits. This proposed LCD dramatically restricts coverage of and access to modern artificial limbs needed by lower limb amputees.

The proposed LCD is a comprehensive re-write of the existing LCDs, addressing all aspects of coding, coverage, and payment of lower limb prostheses for Medicare beneficiaries. The draft LCD is highly restrictive and returns the Medicare prosthetic benefit to a 1970’s standard of care. Because many of the proposed changes involve the Uniform Code Set, which applies to all payers, these policies once finalized are likely to impact all amputees using prostheses, regardless of payer. Many of the changes proposed in the draft LCD raise serious concerns for patients, prosthetists, physicians, and other health care providers and suppliers caring for patients with limb loss.

Public comments on this massive LCD are due on August 31, 2015. There will be a public meeting held by the DME MACs on August 26thin Linthicum, Maryland (close to Baltimore/Washington International Airport) but this meeting is expected to be only one hour long and, considering the enormity of the changes, not a sufficient opportunity for public comment. The Amputee Coalition, along with all O&P provider associations, are strongly opposed to the draft LCD and are engaging in a comprehensive approach to respond to CMS.

In fact, the O&P Alliance sent a letter to CMS Acting Administrator Andy Slavitt on July 31, 2015 requesting immediate rescission of the LCD and a more rational process to examine this Medicare policy or, in the alternative, a suspension of the LCD until CMS holds a national meeting open to the public to focus on this LCD in depth.

Among the themes raised by the draft LCD are the following. The proposed LCD:

  • Eliminates or restricts coverage of multiple prosthetic knees, feet and ankles that have undergone years of development, coding assignment, and widespread use by Medicare beneficiaries, causing them to live with prosthetic technology that is outdated and not consistent with the current standard of care;
  • Eliminates twenty years of precedent by barring consideration of a beneficiary’sfunctionalpotentialand instead relying on “their documented performance using their immediately previous prosthesis (either preparatory or definitive)”when making a determination of the amputee’s functional level. This new standard will drive beneficiaries into less functional prostheses and older prosthetic limb technology, some of which is no longer even available on the market;
  • Creates multiple, new barriers to prosthetic care that will delay and, in some cases, deny prosthetic care to beneficiaries with limb loss. These barriers include the requirement for the beneficiary to undergo full rehabilitation programs before even being eligible for prosthetic coverage, secure detailed documentation from a newly designated set of providers known as “licensed certified medical professionals” or “LCMPs,” and satisfy other prerequisites before a prosthetist can even interact with the patient;
  • Eliminates the licensed/certified prosthetist—who has the most intricate knowledge of prosthetic care—in determining an amputee’s functional capabilities/deficiencies which help determine the treatment plan designed to meet the specific functional needs of the amputee. The proposed LCD creates a new system where physicians, therapists, and others (not prosthetists) will be required to conduct subjective and objective functional assessments and develop significant documentation with little or no additional reimbursement;
  • Fundamentally reworks the HCPCS coding system that has been developed and annually refined over the past forty years whereby “base” prosthetic codes are augmented with “add-on” codes to ensure that beneficiaries receive the most appropriate combination of prosthetic techniques, materials, and technologies to meet their specific functional needs and functional potential. (The DMAC Medical Directors have essentially usurped the authority of the HCPCS Coding Committee which has responsibility for maintaining and refining the Uniform Code Set used by all payers.);
  • Eliminates coverage of some of the most effective suspension and fitting techniques to secure a snug fit between the residual limb and the prosthesis, techniques and technologies that are in widespread use today. Poor or inconsistent suspension and fit during the course of a day’s use of prosthetic limbs is a major contributor to skin breakdown and reduced function;
  • Eliminates access to certain prosthetic components if the amputee uses a cane, crutch, or walker to assist in ambulating, or cannot achieve “the appearance of a natural gait” while using a prosthesis—perhaps one of the most offensive proposals to Medicare beneficiaries;
  • Contains a long set of requirements a patient must satisfy before being eligible to receive prosthetic care, including upper body strength, adequate posture, cognitive capability, sufficient neuromuscular control, sufficient cardio-vascular capacity, and numerous other prerequisites. While consideration of this medical information is not unreasonable, this appears to be a thinly veiled attempt to use the existence of these conditionsto disqualify amputees for coverage of more advanced levels of prosthetic care, or any prosthetic care at all. These requirements are overly broad, not medically supported, and will lead to denials of claims based solely on historical, clinical records, not the physician’s judgment that a beneficiary is a candidate for prosthetic care; and,
  • Reiterates misguided Medicare policies that prohibit the prosthetist’s clinical notes from being considered as part of the medical record and requires new and unnecessarily-detailed proof of delivery documentation which invites denials of prostheses already delivered to patients.

This new LCD’s comprehensive changes to coverage, coding and payment of lower limb prostheses will drive practice in the future and severely limit access to modern prosthetic technology and the current standard of care. The LCD was released with absolutely no evidence cited for these major changes. When a bibliography was finally produced, it contained generic references, outdated articles, newspaper citations, and even references to legislation that has not become law. Yet, the LCD places the burden on the patient and provider community to offer evidence to rebut these proposals with a very limited timeframe.

What You Can Do To Help

  1. Sign the Petition: A “We the People” petition has been established on the White House website. If 100,000 individuals sign this petition, the White House is obligated to respond. The petition can be easily accessed at Please distribute this link to anyone you feel might be interested in signing the petition, including via Twitter, Facebook, and email.
  1. Submit Comments and Get on Record: All organizations and individuals are encouraged to submit comments to the proposed LCD by August 31st. This will ensure that the Medicare program hears widespread opposition to the proposal. Template letters and other materials to assist in commenting can be found at

Please contact us if we can be of any assistance in this matter.

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