Talking Points
Response to Medicare LCD on Lower Limb Prostheses
What: A new proposed Local Coverage Determination (LCD) for Lower Limb Prostheses
(DL33787) has been issued by the DME Medicare Administrative Contractors (DME MACs).
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The draft LCD is comprehensive, complex, internally inconsistent, and completely rewrites coverage, coding and payment policy developed and refined over the past three
decades.
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The new policy is so restrictive that it will send amputees back to 1970’s prosthetic
technology and severely harm the current standard of care.
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The new policy was proposed without virtually any clinical or scientific evidence.
Evidence that was cited is poor quality, often decades old, and generic in nature.
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The LCD will limit the ability of patients to get the care they need to be as functional and
independent as possible. It restricts the prosthetist from recommending treatments and
burdens physicians and therapists with major increases in documentation.
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The VA will be forced to adopt some of these policies and private payers are expected to
follow suit, impacting virtually all amputees across the country in the near future.
When: Written comments on this policy are due to CMS by August 31st. A public comment
meeting will be held on the morning of August 26th in Baltimore, Maryland. Those attending the
public meeting in person or by phone must register by Friday, August 21st, whether or not they
wish to speak. Go to www.SaveProsthetics.org to register for this important public meeting.
Why: Given the success story that prosthetic care represents in this country, it is not clear why
these drastic changes have been proposed. The presumption is that this is an attempt to simply
save federal Medicare dollars, but this should not be accomplished but cutting services to
amputees.
What is the problem they are trying to solve?
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Medicare spending for 2005-2010 shows significant increases in amounts spent for
advanced prosthetics at a time when the number of Medicare beneficiaries stayed
relatively flat.
During these years, the innovative prosthetic components prompted by major federal
research investments by DoD, VA, and others directed to wounded warriors were
becoming the standard of care for military and civilian amputees.
However, Medicare expenditures for all prosthetics peaked in 2010 and has declined
every year since, a 13.8% decrease between 2010 and 2013.
Medicare policies since 2010 have driven patients into older and cheaper technology,
which is typically less functional for the amputee.
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The Medicare program spends about as much on prosthetics today as it did in 2005.
Today, Medicare annually spends approximately 1/3 of one percent of its overall budget
on all orthotic braces and prosthetic limbs combined.
CMS and the DME MACs have now proposed an LCD that seems to be based on a fear
that prosthetic spending is increasing at its 2005-2010 levels. But they have ignored the
past five years of data that tell a very different story.
If the new LCD is implemented, it will restrict access to modern prostheses dramatically,
even further than the current Medicare spending trend.
Request:
Rescission: CMS should rescind the proposed LCD and meet with stakeholder organizations to
discuss any concerns that CMS has with the prosthetic benefit to develop policy in a more
rational, evidence-based, and transparent manner.
Suspension: In the alternative, CMS should suspend this proposed LCD indefinitely until further
discussions with stakeholder groups can be held, CMS makes major changes to the proposed
LCD, and CMS issues the final rule on Prior Authorization of Lower Limb Prostheses, which is
pending review at HHS.
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