responses to "cosmetic covers"

responses to "cosmetic covers"

Karl Entenmann

6/9/2007

Hello colleagues,
Thank you for the many responses to my inquiry regarding medical justification for cosmetic protective shaped covers. The question was in response to an insurance company insisting that I offer a medically justification for a shaped cover on a leg prosthesis. Most of the responses suggested that the cover was necessary to protect the adjustable componentry of the prosthesis, protect clothing and the wearer or small child from the sharp componentry, and to promote body image. There were many responses and here are a few. Any omitted are similar to these.


A custom shaped protective cover is medically necessary for protecting

the components of the prosthesis and making them inaccessible by the

patient to avoid self-adjustment. The covering also helps to fill in a

wearers pant leg, and to help protect the wearers clothing. The foam

is typically shaped like the patients sound extremity. When this foam is accompanied by a flexible protective outer covering they together

ensure a longer life of the prosthetic components.
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The prosthesis will not function properly if the components are exposed to excessive environmental moisture. Things like rain, walking through puddles, cars splashing by the sidewalk, etc are causes of normal environmental moisture. A cover protects the internal components from premature wear and tear. While we're add it, we shape the cover to look like a normal leg, but that's just because we're nice guys. The cover is designed to be protective, and should be described that way.
   
  Another line of argument: According to the AMA, cosmetic surgery is the term used to describe altering a normal, functioning body part to make it look different. Restorative surgery is performed on malformed or malfunctioning body parts, and may be done to restore a normal shape and structure. A cover on a prosthesis is the functional component that restores the shape of a lower extremity - it is not cosmetic. A pipe does less of a job of restoring what was amputated. This argument is a little more nuanced, so it might not work very well, especially on insurance company employees who would all gladly have their son, daughter, father, mother, wife, husband fit with a nothing more than a pipe if they lost their leg.
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  Prosthetic covers ARE medically necessary because they keep out dust, salt, and other items that can rust, corrode, and otherwise damage the prosthetic leg and components. If you live in an area near water, a desert area, or a particularly rainy area, I would add that information in the appeal as well. In fact, without the prosthetic cover you may actually be decreasing the lifetime of the much more expensive prosthetic components. This would lead to a need for replacement parts sooner, which would translate into an additional financial burden on the insurance company.
  Medicare recognizes this, and they pay for these. All you are asking for is that they follow, as a minimum, Medicare coverage. If you look at the code descriptions for prosthetic covers, these are described as PROTECTIVE COVERS. You may be surprised how much more success you will have getting a 'Protective Cover' paid for as opposed to a 'Cosmetic Cover'.
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The functional, adjustable alignment component elements of prosthesis must be protected from damage in the patient’s daily environment, and elements of nature. An example is getting in/out of an automobile; can damage a vacuum pump, suspension sleeve, hydraulic control unit, etc.
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And, I love this one:


The true purpose of the cosmetic cover is not for looks, but a

protection of the investment by the insurance company and patient. ISO

standards state that a component must withstand 3 million cycles.

These components include the pylon, pyramid, knees, feet etc. Now with a patient that averages 1 mile/day, this equates to 1.5-2 million cycles/year. Thus the life span of the components for the average walker is about 2 years.

Now, according to test performed at Fillauer, 1 scratch to the anodizing on a pylon has the potential to reduces the maximum cycles to 150,000. This is a huge reduction in the strength and longevity of a component. This same reduction can also be seen with corrosion and oxidation.

Therefore, each of the 2 components in a cosmetic cover has a specific

purpose. The custom shaped protective cover provides shock/cushioning

protection against those aforementioned dings and nicks. The skin

provides a mosture barrier to guard against oxidation and corrosion.

These two covers help to reduces the components to mechanical and chemical damage, protecting the insurance companies investment while reducing all parties exposure to risk associated to a reduced life expectancy of the mechanical device.
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Karl W Entenmann, CPO
Preferred O and P
Federal Way, WA