Responses to Medicare Policy regarding a second prosthesis
Herb Shalant
Description
Collection
Title:
Responses to Medicare Policy regarding a second prosthesis
Creator:
Herb Shalant
Date:
2/4/2016
Text:
Question posed: Do you know what Medicare's policy is regarding having more
than 1 prosthesis at any one time?
Do they support and pay for a sports leg for instance or a 2nd prosthesis
because one has a low heeled foot and the other a high heeled foot?
Or is it limited to a medical necessity where a person might be engaged in
active employment where they work in an environment (for instance water)
where they NEED a different type prosthesis than an ordinary ADL prosthesis?
Or they play basketball recreationally and need a prosthesis that will
respond appropriately ? Or run track recreationally?
Herb Shalant, C.P.O.
White Plains, NY
Responses: .. Unless you can find a way to justify medical necessity of two
different prostheses, it appears they do not want to cover two.
Back up or precautionary equipment does not meet the definition of a covered
benefit (see bottom of pg 3 /top of page 4) First, one must identify the
original RX and delivery date; Second, determine if this equipment was
replaced; and 3 -if there was need to replace it with another prosthesis, it
should be no longer fitting and appropriate (or there would have been no
need for the next prosthesis). Therefore, repairs and replacements to the
back up equipment are non-covered.
Medicare does not pay for sport or swim prosthesis.
Medicare's medical necessity rules do not support multiple feet or
prostheses.
If a patient needs to change heel height I supplest using one of the
adjustable feet like Accent or Ossur's adjustable foot.
I have people use their old prosthesis for water stuff or roughing around.
Sometimes I will make them a socket at a reduced rate when I make a new leg
because I already have the mold and alignment.
If there were circumstances where it was covered, that would be AWESOME.
Medicare bases payment for each prosthesis on medical necessity, and to
allow the person to complete the necessary activities of daily living that
are essential. I find it extremely unlikely that Medicare is going to pay
for an additional prosthesis on the basis of the heel height for sports. I
could not even say with great confidence that it would be considered for the
purpose of employment with extraordinary demands. Medicare will typically
cover one device at a time, and will question why that device cannot be
repaired or modified to meet the new needs that the patient may have.
If you were asking about a private payor, I may have a different opinion,
but I think it is unlikely that you will get very far with Medicare.
You must not deal with Medicare, ever. Or, this is a hoax question. Assuming
the question is legitimate, they only pay for 1 every 5 years and that is
only if all criteria are met, T's crossed I's dotted and then they still may
claw the money back in an audit. But also, I thought NY was still fighting
the one limb for life ruling? Oh wait, yes he can have a 2nd leg for cash!
NO on all counts.
---
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than 1 prosthesis at any one time?
Do they support and pay for a sports leg for instance or a 2nd prosthesis
because one has a low heeled foot and the other a high heeled foot?
Or is it limited to a medical necessity where a person might be engaged in
active employment where they work in an environment (for instance water)
where they NEED a different type prosthesis than an ordinary ADL prosthesis?
Or they play basketball recreationally and need a prosthesis that will
respond appropriately ? Or run track recreationally?
Herb Shalant, C.P.O.
White Plains, NY
Responses: .. Unless you can find a way to justify medical necessity of two
different prostheses, it appears they do not want to cover two.
Back up or precautionary equipment does not meet the definition of a covered
benefit (see bottom of pg 3 /top of page 4) First, one must identify the
original RX and delivery date; Second, determine if this equipment was
replaced; and 3 -if there was need to replace it with another prosthesis, it
should be no longer fitting and appropriate (or there would have been no
need for the next prosthesis). Therefore, repairs and replacements to the
back up equipment are non-covered.
Medicare does not pay for sport or swim prosthesis.
Medicare's medical necessity rules do not support multiple feet or
prostheses.
If a patient needs to change heel height I supplest using one of the
adjustable feet like Accent or Ossur's adjustable foot.
I have people use their old prosthesis for water stuff or roughing around.
Sometimes I will make them a socket at a reduced rate when I make a new leg
because I already have the mold and alignment.
If there were circumstances where it was covered, that would be AWESOME.
Medicare bases payment for each prosthesis on medical necessity, and to
allow the person to complete the necessary activities of daily living that
are essential. I find it extremely unlikely that Medicare is going to pay
for an additional prosthesis on the basis of the heel height for sports. I
could not even say with great confidence that it would be considered for the
purpose of employment with extraordinary demands. Medicare will typically
cover one device at a time, and will question why that device cannot be
repaired or modified to meet the new needs that the patient may have.
If you were asking about a private payor, I may have a different opinion,
but I think it is unlikely that you will get very far with Medicare.
You must not deal with Medicare, ever. Or, this is a hoax question. Assuming
the question is legitimate, they only pay for 1 every 5 years and that is
only if all criteria are met, T's crossed I's dotted and then they still may
claw the money back in an audit. But also, I thought NY was still fighting
the one limb for life ruling? Oh wait, yes he can have a 2nd leg for cash!
NO on all counts.
---
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Citation
Herb Shalant, “Responses to Medicare Policy regarding a second prosthesis,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/242012.
