Special Alert: Major Developments in O&P Policy

Over the past two weeks, a number of major, long-awaited developments in O&P policy have occurred. NAAOP and its Alliance partners have been diligently working on these measures over the past few years and we are excited to share an update on the progress that has been made.

  • Issuance of CMS Interagency Workgroup’s Consensus Document: After publishing a DME MACs Draft Local Coverage Determination (LCD) for Lower Limb Prostheses in 2015 that caused enormous public comment and concern, CMS placed that document on hold and formed an Interagency Workgroup in February 2016 to further explore the issues. Last week, CMS published the results of the Workgroup’s efforts. The Workgroup has recommended CMS to take the following immediate actions:
  • Instruct the DME MACs to remove the 2015 Draft LCD and continue coverage for lower limb prostheses under the current LCD, with no changes.
  • Support the establishment of an interagency federal research group in order to create a guidance document to promote industry research standards in the field of lower limb prostheses.
  • Consider creating a National Coverage Determination (NCD) to evaluate the use of microprocessor knees (MPK) for individuals using their prostheses as a limited community ambulator (K2 functional level).

The removal of the draft LCD is a major victory for the O&P community. However, there are still significant areas of concern in the Consensus Document that could be improved. These include:

  • The recommendation that CMS move toward pre-authorization of lower limb prostheses, a process led by the DME MACs.
  • The characterization of prosthetists as “consultants” to the physician for purposes of determining functional level.
  • The conclusion that current literature does not support improved functional health outcomes of power assist ankles and vacuum systems. Nonetheless, these devices may be covered if justified in the pre-authorization request.

Note: On June 21st, the DME MACs announced the retirement of the Draft LCD on Lower Limb Prostheses. This Draft LCD is finally dead.

  • Release of the MEDPAC Report on Orthotics: The Medicare Payment Advisory Commission (MEDPAC) report, filed with Congress last week, includes a substantial section on orthotics and recommends implementation of competitive bidding for off the shelf (OTS) orthotics. However, the report largely focused on abuses of this benefit by non-orthotist providers and even suggested that orthotists, like physicians, should be able to provide OTS orthotics without having a Medicare competitive bidding contract. Importantly, the report did not recommend expansion of competitive bidding to all orthotics and prosthetics, a policy that had been considered prior to NAAOP and its Alliance partners meeting with MEDPAC staff.
  • VA Report by OIG: Over the next few weeks, we expect to see a report from the Office of Inspector General (OIG) of the Department of Veterans Affairs (VA) that may impact coding and coverage of orthotics and prosthetics. We will share this with you when we learn more.
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