Re: Medicare denials for broken beyond repair carbon AFOs

Re: Medicare denials for broken beyond repair carbon AFOs

PMS

4/16/2021

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?




Carey Jinright, LO, MSM
WDJD
Be an example, not an excuse!

Confidentiality Notice - The information contained in this e-mail and any attachments to it may be legally privileged and include confidential information. If you are not the intended recipient, be aware that any disclosure, distribution or copying of this e-mail or its attachments is prohibited. If you have received this e-mail in error, please notify the sender immediately of that fact by return e-mail and permanently delete the e-mail and any attachments to it. Thank you.
 


> On Apr 16, 2021, at 7:26 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
>
>