Re: Medicare denials for broken beyond repair carbon AFOs
Marty Mandelbaum
Description
Collection
Title:
Re: Medicare denials for broken beyond repair carbon AFOs
Creator:
Marty Mandelbaum
Date:
4/19/2021
Text:
Hi Listserv,
Thanks for your responses. It seems as though Medicare still denies the
replacement of broken beyond repair carbon AFO's even though their
guidelines say that it is covered.
Following their rules is *not a guarantee of payment!* (Don't you love that
phrase?)
Best,
Marty
On Fri, Apr 16, 2021 at 5:56 PM Marty Mandelbaum < <Email Address Redacted> >
wrote:
>
> Wondering how many of you still get denied after reconsiderations even
> though the physician, patient and orthotist all document that device is
> broken beyond repair after a specific incident causing the failure?
> Best
> Marty Mandelbaum CPO
>
Responses:
1- Happens ALL the time!
It’s so bad, we make them sign bf fully pay upfront now because of it.
Provide picture etc as well.
Sent from my iPhone
Travis A. Young, CPO
OPAF President
2- Don’t you love Medicare?
Karl
3- Yes still get denied. We’ve had to go to an unfortunate rule of 5
years for afos unless there’s a police report of stolen or there’s proof of
it broken in a car accident (car insurance claim). It’s absolutely insane.
Brittany Stresing, CPO FAAOP
4- I understand your question and many will respond that carbon AFOs will
all fail and that maybe carbon should not be used in the place of plastics.
So, I would like to broaden your inquiry. Why are we held to a RUL that is
not backed by, or supported with any data? PDAC has been appointed for
years to determine the coding category for items within our industry. PDAC
determines, or is at least blamed for the RUL that is set. When you ask,
“Who said that a carbon fiber AFO will last five years?” No one has an
answer. What tests were performed to show that the cyclical requirements of
an everyday user were met prior to an AFO (or any other product) having
been given a code? I truly believe the five year RUL is outside of reality.
I also do not believe that they can prove it to be justifiable in most
products! The research that I have seen regarding carbon fiber AFOs shows
460,000 cycles on a sagittal plane device mimicking dorsal and plantar
flexion prior to de lamination. This does not count the transverse plane
motions or that of spasticity, tone, edema, or real life activities on
uneven terrain. If you have an end user that walks 1,000 steps per day this
research would mean the brace would last 1 1/2 years. That is just 1,000
steps per day! My point is, where is the evidence that CMS or PDAC has
based the 5 year RUL on? This does not only apply to carbon AFOs but wrist
splints, ankle braces, and items that anyone would know will not last a
daily user five years! We as an industry have set back and allowed this
fictitious number to become the benchmark when there is not any clinical
evidence for its existence. Now auditors are having a feeding frenzy based
off of an unrealistic standard.
Does anyone want to discuss denials listed as “same or similar” based off
of the categorization of products in the LCD? An SI belt is the same or
similar as a TLSO, really!? A cam walker boot is the same as an AFO,
really? A wrist splint and a resting hand splint?
Want to discuss the demand for a master’s degree in a field that does not
get any reimbursement for their evaluations, education, or patient care? We
have been reduced to being paid for a product as long as I can remember.
The manufacturer’s rep is paid the same as the Certified Orthotist, really?
Any time I bring these issues up, I am told I need to join this group, or
pay dues to this association. Can I at least hear the fight for these
topics being mentioned before I am asked for my check book?
5- We had the same issue just this month. They denied the first
reconsideration. Will continue to appeal even up to the administrative law
judge.
Steven Hunter, CPO
Thanks for your responses. It seems as though Medicare still denies the
replacement of broken beyond repair carbon AFO's even though their
guidelines say that it is covered.
Following their rules is *not a guarantee of payment!* (Don't you love that
phrase?)
Best,
Marty
On Fri, Apr 16, 2021 at 5:56 PM Marty Mandelbaum < <Email Address Redacted> >
wrote:
>
> Wondering how many of you still get denied after reconsiderations even
> though the physician, patient and orthotist all document that device is
> broken beyond repair after a specific incident causing the failure?
> Best
> Marty Mandelbaum CPO
>
Responses:
1- Happens ALL the time!
It’s so bad, we make them sign bf fully pay upfront now because of it.
Provide picture etc as well.
Sent from my iPhone
Travis A. Young, CPO
OPAF President
2- Don’t you love Medicare?
Karl
3- Yes still get denied. We’ve had to go to an unfortunate rule of 5
years for afos unless there’s a police report of stolen or there’s proof of
it broken in a car accident (car insurance claim). It’s absolutely insane.
Brittany Stresing, CPO FAAOP
4- I understand your question and many will respond that carbon AFOs will
all fail and that maybe carbon should not be used in the place of plastics.
So, I would like to broaden your inquiry. Why are we held to a RUL that is
not backed by, or supported with any data? PDAC has been appointed for
years to determine the coding category for items within our industry. PDAC
determines, or is at least blamed for the RUL that is set. When you ask,
“Who said that a carbon fiber AFO will last five years?” No one has an
answer. What tests were performed to show that the cyclical requirements of
an everyday user were met prior to an AFO (or any other product) having
been given a code? I truly believe the five year RUL is outside of reality.
I also do not believe that they can prove it to be justifiable in most
products! The research that I have seen regarding carbon fiber AFOs shows
460,000 cycles on a sagittal plane device mimicking dorsal and plantar
flexion prior to de lamination. This does not count the transverse plane
motions or that of spasticity, tone, edema, or real life activities on
uneven terrain. If you have an end user that walks 1,000 steps per day this
research would mean the brace would last 1 1/2 years. That is just 1,000
steps per day! My point is, where is the evidence that CMS or PDAC has
based the 5 year RUL on? This does not only apply to carbon AFOs but wrist
splints, ankle braces, and items that anyone would know will not last a
daily user five years! We as an industry have set back and allowed this
fictitious number to become the benchmark when there is not any clinical
evidence for its existence. Now auditors are having a feeding frenzy based
off of an unrealistic standard.
Does anyone want to discuss denials listed as “same or similar” based off
of the categorization of products in the LCD? An SI belt is the same or
similar as a TLSO, really!? A cam walker boot is the same as an AFO,
really? A wrist splint and a resting hand splint?
Want to discuss the demand for a master’s degree in a field that does not
get any reimbursement for their evaluations, education, or patient care? We
have been reduced to being paid for a product as long as I can remember.
The manufacturer’s rep is paid the same as the Certified Orthotist, really?
Any time I bring these issues up, I am told I need to join this group, or
pay dues to this association. Can I at least hear the fight for these
topics being mentioned before I am asked for my check book?
5- We had the same issue just this month. They denied the first
reconsideration. Will continue to appeal even up to the administrative law
judge.
Steven Hunter, CPO
Citation
Marty Mandelbaum, “Re: Medicare denials for broken beyond repair carbon AFOs,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255481.
