Prosthetists, amputees left out of process

Friday, November 6, 2015

WASHINGTON – CMS has shelved its plans to change the coverage requirements for lower limb prostheses in favor of forming a workgroup to revisit the issue, but O&P stakeholders say they won’t be involved.

The workgroup will be comprised of clinicians, researchers, policy specialists and patient advocates from different federal agencies, according to a CMS announcement last week.

“One of our disappointments is that this is a working group of federal employees of federal agencies,” said Tom Fise, executive director of the American Orthotics & Prosthetics Association. “There is unlikely to be any way that stakeholders, be they patients or prosthetists, are going to be well represented in that interagency working group.” 

The workgroup has been tasked with developing a consensus statement based on a review of the available clinical evidence that defines best practices in the care of beneficiaries who require lower limb prostheses. The statement will inform future policy.

The four DME MACs in July released draft local coverage determinations for lower limb prosthetics that proposed requiring patients to have face-to-face visits and requiring them to complete rehab programs. That resulted in an uproar from the O&P community, including a public hearing, a protest, and a “We the People” petition that netted more than 100,000 signatures.

“Both CMS and its contractors have heard your concerns about access to prostheses for Medicare beneficiaries,” the agency stated in the announcement. “The DME MACs will not finalize the draft local coverage determination at this time.”

Fise, however, says it would better if CMS rescinded the policy outright, before commercial insurances start picking up on it. “Bottom line, if it’s not going to go forward because of deficiencies, then it would certainly be very helpful for the documentation to be taken down from the CMS and MAC websites,” he said. “UnitedHealthcare already picked up one of the provisions and a long examination of the topic doesn’t change commercial payers once the pick it up.”

UnitedHealthcare has issued guidelines stating that it will no longer cover vacuum pumps, according to AOPA.

CMS, for its part, says it will “ensure there is opportunity for public comment and engagement on the consensus statement and any related activities.”