Responses to: USA medicare useful lifetime

Responses to: USA medicare useful lifetime

Gary A. Lamb

8/4/2003

Dear list thanks for the help and support, the original question follows
along with the replies. Most of these I’ve left the name off since there was
usually extra non related information in the reply, prior to the signature.
Yes, I am somewhat lazy.

Thanks again to all.

Gary A. Lamb LPO, CO, FAAOP
C.O.P.E.
Comprehensive Orthotic-Prosthetic Enterprises
1742 Hickory St.
Abilene, TX. 79601

<Email Address Redacted>

Subject: [OANDP-L] USA: Medicare useful lifetime


> Dear List,
>
> Recently we are getting medicare rejections for replacement due to the
> useful lifetime. Everything we can find on region C says 5 years. I
thought
> I read this was reduced to 3, but I’m not finding an official source.
Maybe
> it was a dream. Any help?

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If you establish medical need/change or unable to repair, (total repairs
exceed new cost), Medicare will have to replace.
An added note: I'm not sure 5 years is actually in the Medicare guidelines.
It was told to me that 5 years was an arbitrary number established by the
Director of Region C.
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Don't know of a resource for ya but I heard it was 5 yrs for orthotics
and 3 yrs on prosthetics.... let me know what you find out.
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I wanted to let you know that from what we find Prosthetics was reduced to 3
years, but Orthotics is still 5 years.
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    Hope all's well with you and your family.
If replacement is due to physiologic change, it supercedes the useful time
requirement.
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Region C has begun to enforce the 5-year rule. Sucks when it comes to
corsets and other soft goods wearing out within 5 years!!
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We are running into the same problem. In fact, after we request reviews on
the denials the reviews are denied based on this five year guideline. We
are in the process of having fair hearings and we are citing coverage
regulations based on OBRA 90, Code of Federal Regulations, Social Security
Act, and Medicare Carrier's Manual. The issues are medical necessity,
reasonable lifetime, and irreparable damage. We have won some fair
hearings and have had to go to ALJ on several. We have never lost an ALJ.

Per Section 414.229 of the Code of Federal Regulations: ...if a purchased
item of DME or a prosthetic or orthotic device paid for under this subpart
has been in continuous use by the patient for the equipment's reasonable
lifetime or if the carrier determines that the item is lost or irreparably
damaged, the patient may elect to obtain a new piece of equipment. This
section goes on to stipulate that reasonable lifetime can be no less than
five years. However, if the carrier is unwilling to budge on the
reasonable lifetime issue, replacement based on irreparable damage becomes
an option. The bottom line is if the item is medically necessary and the
patient doesn't have one that is functional, Medicare has to pay...it just
may take an ALJ to make it happen.

Another problem that we recently experienced was refund requests for P & O
services provided in SNFs. The requests were based on regulations posted in
a 1993 carrier's manual. The patients in question were either provided
prosthetic services excluded from the SNF consolidated billing, or orthotic
patients who were over the 100 day limit per the April 1, 2000 changes.
The problem with this is that refunds have to made before the appeals are
resolved.

It looks like we are starting to face yet another abuse by Region C.
Apparently clerks who don't know their own regulations are being given the
authority to audit, deny, and request refunds. It is ashame that the legal
separation of P & O from DME in OBRA 90 was not enough for the former HCFA
(now CMS) to modify its handling of P & O to reflect this change.

Good Luck.

Jim Price, PhD, CPO
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If there are documented physycal changes, i.e: weight, activity level, etc.
then a replacement socket, componet component upgrade or prosthesis is
possible. These changes need to be backed up by your follow-up, physician
notes, second amputation, etc. They also have to provide direct benefit to
the patient.
Robert L Hrynko, CPO/LPO
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you are correct, it is three years. I believe the legislation changing the
time was either with the NRM legislatio or at the same time. Contact AOPA,
they should have the Federal statutes.
Morris
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You might want to try getting hold of Kathy Dodson at AOPA, she will be able
to help you. I don't have her phone number, but her email address is:
<Email Address Redacted>

Good luck,
Kim Edgar
Office Manager
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No you are not dreaming, I remember it also, and I cannot find the reference
either. If you get positive responses, please forward to me
Thank you
Casey Pimpinella
Medicare Biller
Klemmt Orthopaedic Services
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It was 3 at one time, but in November 2002, on the Palmetto website. If you
go to PalmettoGBA.com-Providers/DMERC/General Information (Limitation on
Orthoses Code...) There is a whole page on the limitation on orthoses
codes. The expected useful lifetime of orthoses is five years or greater.
Replacement can only be covered if the item is lost, irreparably damaged or
the patient's needs or conditions have changed. Replacement is not covered
for irreparable wear during the five year period.
To cover yourself, you need to have each patient sign an Advance Beneficiary
Notice (ABN). This lets them know that medicare may not pay for their
orthosis if they received one within the last five years. Then they have
the option of getting it or not. They sign and date it and when you file
the claim with Medicare you use the GA modifier, this let Medicare know that
you already let the patient know that this may not be covered and if it is
denied you can bill the patient. Because if you do not get this signed and
use this modifier, you will end up writing off the item or appealing or
both.

Barbara Crowe
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Walt Gorski from AOPA called me to update me on AOPA’s work in this arena.
Briefly, the rule has been on the books since the 90’s, it is now being
enforced at least in region C. They met with CMS in April on this specific
issue to no avail. Bottom line is document medical necessity, describe why
device no longer meets medical necessity, appeal.
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