Powers attorneys Peter W. Thomas, Leela Baggett, and Michael Barnett recently assisted clients in helping to secure expanded Medicare coverage for microprocessor-controlled prosthetic knees (“MPKs”)—including fluid and pneumatic knees—for less functional Medicare beneficiaries with a fear of falling. The new policy is a major improvement of Medicare’s coverage policy for beneficiaries with lower limb loss to reduce the incidence of falls, the fear of falling, injuries from falling while ambulating, and to improve function. Powers clients engaged in this work include the National Association for the Advancement of Orthotics and Prosthetics, the Orthotic and Prosthetic Alliance, and members of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition.
On July 18, 2024, the Centers for Medicare and Medicaid Services (“CMS”) and the Durable Medical Equipment Medicare Administrative Contractor (“DME MAC”) Medical Directors released a much-anticipated final Local Coverage Determination (“LCD”) L33787 Lower Limb Prostheses. They also published an updated Policy Article that offers additional details on this new coverage policy. The effective date for this final LCD is September 1, 2024.
Powers worked earlier this year to submit extensive comments to the proposed LCD, stressing the importance of this new coverage policy for Medicare beneficiaries with limb loss. The documentation to demonstrate medical necessity must include how the selected knee will improve the beneficiary’s functional health outcomes and help the beneficiary accomplish his or her activities of daily living. In addition, alternative lower-level knee options must be determined to have been considered and ruled out based on the beneficiary’s individual functional and medical needs. The LCD also addresses complimentary prosthetic foot options for Medicare beneficiaries who qualify under the new coverage policy.
In the past two years, Powers has worked closely with numerous clients on what appears to be a new trend at CMS for expanding coverage of prosthetic, orthotics, and durable medical equipment. ITEM Coalition took the lead in helping to secure coverage of seat elevation in power wheelchairs to improve the ability of beneficiaries to reach for objects and perform Mobility Related Activities of Daily Living (MRADLs) in the home. CMS has also created a billing code for bone-anchored prostheses, paving the way for access to osseointegrated prostheses for Medicare beneficiaries who do not respond well to traditional prosthetic socket technology.
Last year, CMS determined that orthoses that employ the use of powered features are considered under the orthotic benefit category, leading to coverage of exoskeletons that assist beneficiaries with paralysis to stand and ambulate. This decision also established coverage of powered orthoses that assist beneficiaries with stroke and other conditions to perform upper extremity Activities of Daily Living (ADLs). The MPK coverage expansion is the latest improvement to the Medicare benefit package in this area and will likely have a ripple effect in how private health care plans and other insurance programs cover these benefits in the future.
This finalized coverage policy is a major improvement in lower limb prosthetic coverage for Medicare beneficiaries with limb loss and limb difference. It comes after 20 years of clinical research, eight years after CMS stated that the Medicare program should consider coverage of MPKs for an expanded beneficiary population, and major efforts by stakeholders to improve Medicare coverage in this manner.