The Dominoes Begin to Fall

falling dominoesThe publication of the Medicare draft LCD and Policy Article for Lower Limb Prostheses obviously caused great concern within the O&P community as evidenced by the huge show of support during the August 26th public meeting and rally at DHHS headquarters.  A consistent question that has been heard since the release of the policy is: How long will it take to see the affects of this policy trickle down into the private insurance market.  The answer to that question, unfortunately, is not long at all.

In its most recent medical policy bulletin published in August of 2015 and effective for dates of service on or after October 1, 2015, United Healthcare, currently the largest insurer in the United States, issued a policy statement that states, “The use of vacuum pumps for residual limb volume management and moisture evacuation systems among amputees is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer-reviewed medical literature”.  A remarkably similar statement in the Medicare draft LCD and Policy Article states that claims for HCPCS codes L5781 and L5782 which describe vacuum based residual limb volume management and moisture evacuation systems will be denied as not medically necessary because there is “insufficient published clinical evidence to support these claims.”  While I try to never be pessimistic about things, the timing of this policy decision by United Healthcare, along with the similar language that appears in both policies forces me to question the genesis of the United Healthcare coverage decision.

During its meeting with high ranking CMS and HHS officials on the afternoon of August 26th, AOPA expressed its deep concern that while the policy published by Medicare was done so as a draft, with no bearing on current claims for lower limb prostheses, private insurers would be quick to use language in the draft to justify policy decisions regarding coverage of lower limb prostheses.  Unfortunately, It appears that AOPA’s concern was well founded.

AOPA has provided CMS and HHS with a copy of the recent United Healthcare policy bulletin to drive home the point that the language from the draft LCD and Policy Article is already being picked up by private insurers, and has also reached out to United Healthcare directly to discuss this policy decision.  As this issue progresses, AOPA will provide updates regarding the future coverage of vacuum based volume management and moisture evacuation systems by Medicare and private payers.

The decision by United Healthcare to declare vacuum based volume management and moisture evacuation systems will not be the last decision that is based on language in the Medicare draft LCD and Policy Article.  It is important that you review any policy bulletins you receive that appear to limit coverage of prosthetic services and notify AOPA immediately so we may address these issues promptly.

AOPA’s Take.  Where you go…..When you need to know!!!