Re: Polio/Post Polio Syndrome/Non-ambulatory/Ins Coverage

Re: Polio/Post Polio Syndrome/Non-ambulatory/Ins Coverage

Schwelke, Eric

1/14/2019

Responses to my original post:

GM:

Like a lot of you on this list, I have been at this for quite a few years but still come across cases where I am still uncertain and confused whether a device will considered medically necessary/reasonable by an insurance policy.

Specifically, presented with an long-time patient who contracted polio at a young age and was affected w/ Post Polio Syndrome recently. At this point, they are non-ambulatory and only able to use the orthosis for transfers. Currently using a 26 year old conventional KAFO that has been repaired/refurbished by us since that time and most likely needs to be replaced. Although we will have good medical eval documentation regarding this patient from the physiatrist and rehab clinic, I am still concerned about providing a new KAFO for transfers only and being reimbursed.

My feeling is that if using the orthosis for transfers in ADL's will protect them from a fall, thereby preventing further injury, possibly serious, with a very expensive hospital stay, then this could be considered medically necessary. But we know that insurers can be shortsighted and not consider long term costs.

Would like to know what experiences/opinions you have for this situation?

Thanks in advance for your replies.

7:32 PM:

Thanks for all the quick responses I received in less than a few hours. Of course, I am aware of our regional LCD for Medicare and all the requirements for coverage but for private carriers, we would need to review the Medical Policy for each particular plan that covers the patient (which would hopefully provide their definition of ambulatory), and even then it's a shot in the dark. My long experience with payers is that the benefits staff and the claims staff don't communicate; while the former will say it will be covered and may even issue an authorization (which is typically no guarantee of payment), the claims folks may see things differently.

In the end, it seems that our patient will be covered by a Medicare HMO policy Feb 1; this will require an ABN w/ payment up front and all the medical evaluation documentation. I tend to agree w/ some of the respondents that even if the patient does transfers only using the orthosis, they would be taking at least 1-2 steps even w/ assistance to achieve the ADL they are attempting.

Always a challenge.

Numbered replies in no particular order follow:


1. I'm interested in the responses you get. Would you mind forwarding them to me?

2. Look at LCD. Requirement number one is - patient is ambulatory. This is the foundation. If anywhere in any of doctors notes it says that he is not - you have your answer.

3. It depends on the insurance clinical criteria. Is this for Medicare, Medicaid or a commercial payer?

4. I'm reasonably sure that one of the criteria for a custom brace in the LCD is that the patient has to be ambulatory, and transfers don't count . Sounds like a case to use an ABN unless the dr documents ability to walk . Hope that helps

5. If the patient is covered under a PPO plan for which the insurer will not issue an authorization, we have found some success in requesting a courtesy review prior to service. Not all insurers will agree to this, but when I ask for it I always frame the question as We want to provide the best service possible to your customer; s/he/they will be very upset with us and your company if this service is denied after we deliver the brace. Since you will have to review this case after delivery any way, your customer would really appreciate it if you could to a review ahead of time as a courtesy. Of course, you will need to escalate this ask to a Manager rather than a front line staff member. If that gets no result, I ask the patient to call with a similar type of question and to not give up until they get a firm answer, making sure to document the name of the person and their title.

6. Hi Eric, I believe they would need to be ambulatory or have the potential for ambulation. That is if it is Medicare.

7. The answer to this very much depends on the insurance company. It might be worth it to do a predetermination with all of your documentation to see if they will pay it. Many times a medical director can see the benefit of the device and approve it even if it doesn't meet the specific policy 100%. Unless it's Medicare, which you're kinda stuck with their LCD without exception.

8. I would qualify a patient as non-ambulatory if they were bed bound and could not get out of bed. All other movement would qualify as ambulatory, including transfers. A patient is at high risk for falling during transfers if they do not have a brace and needed one. Just explain the reason the patient would benefit from a custom molded brace to use. Use planes of motion to discuss needed support across all joints involved. Call AOPA to get a clear answer.

9. I have been a user of a KAFO for Polio for more than 60 years , however i use it for ambulation . With that said without my brace, walking would practically be impossible at my age if it were not for some surgery that I had a young age that limited dorsiflexion of the ankle and as a result I can hyperextend my knee like a floor RX afo to walk short distances around the house. However, one false move could trigger my knee and down I go, have done that many times . I can't imagine having to stand without that ankle stability even for a transfer. The patient is at great risk of a serious injury should he or she fall. I see that as justification for the KAFO, otherwise the insurance company could be paying for additional surgeries and a potential long hospital stay.

10. I could be wrong but I consider transfers to be ambulation especially if the person has to take a step or two to get into the chair or to the bathroom. And given the size of some bathrooms or bedrooms they do have to take a few steps for transfers. After all the person is weightbearing unless they use a lift, someone picks them up, or a slide board is involved. A step is ambulation. It depends on what they wrote in their doctor's notes. Hopefully they said something about her ability to ambulate even if it's limited or state she has the potential to ambulate. This could be something to educate the doctor on..describing the fall risk in transfers, KAFO is necessary for ambulation in the home, etc. I work in a rural town and I'm amazed by the number of physically challenged people transferring into trucks that aren't very suitable given their height. If I'm wrong or if others want to weigh in I'm interested in hearing so please post replies just take my name off.

11. It all depends on the insurance carrier. If it's Medicare they won't pay for non-ambulatory, if they have a secondary then hopefully they will cover it. We encounter situations like this frequently and often times they have Medicaid secondary. In Massachusetts Medicaid will cover non-ambulatory, we do an ABN stating they do not meet criteria - Medicare will deny not medically necessary - then you get a patient responsible denial and Medicaid will pay. They understand that the disabled population need different services.

12. Like yourself I have been here for ever. I think my risk approach would depend on the payor. An old polio today must be in their 70's, probably Medicare, maybe medicaid. Without a P.A. it's risky. At this age why not just keep the current one going with repairs.

13. Our team comes across this scenario relatively frequently, so I'll sit down later today and compose a more complete response for you. (In short, your feelings are correct. However, since we're in Australia I definitely won't be able to shed any light on the insurance situation.) Feel free to liaise directly with any specific questions.

14. Being beneficial is different than meeting the criteria of the LCD for coverage by a 3rd party payor. Medically necessary is also different than meeting the coverage criteria, LCD, for the 3rd party insurance to pay. One other aspect for the LCD coverage is in therapy with a goal of ambulation. At least out here, but you will need to check your own LCD.

Thanks to all again for your time.

All the best,

Eric

Eric Schwelke CPO LPO, Director
Kessler O & P Services
11 Microlab Road
Livingston, NJ 07039
Direct Tel: 917 337 7557
Office Tel: 973 863 4231
Direct Fax: 717 635 3920
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