In the wake of a concerted lobbying campaign by the prosthetics industry, the CMS has reversed a recent coverage decision that advocates claimed could have blocked patients' access to artificial limbs.
In July, the agency released a series of identical local coverage decisions that overhauled Medicare reimbursement, coding and clinical-care guidelines for lower-limb prosthetics. A 2011 report by HHS' Office of Inspector General found the agency was spending unnecessary millions on limbs for patients with other, more serious health problems.
While there are only 150,000 amputees covered by Medicare, advocates worried that private payers and the Veterans Health Administration would quickly follow the CMS' lead. That could effect as many as 1.7 million people, they said.
The CMS responded by putting its proposal on the back burner. “Both CMS and its contractors have heard your concerns about access to prostheses for Medicare beneficiaries,” the agency said in a Nov. 2 notice on its site. “The Durable Medical Equipment Medicare Administrative Contractors will not finalize the draft (coverage determination) at this time."
Instead, the agency will pull together a working group comprised of clinicians, researchers, policy specialists and patient advocates to come up with a revised policy. The proposed overhaul was released last summer,
Medicare spending for lower-limb prostheses increased 27% between 2005 and 2009, according to the OIG report, reaching a total of $655 million. The number of patients decreased 2.5% over the period.
The CMS' original proposal declared that the new payment schedule was not intended to restrict any medically necessary prostheses. Various orthotics and prosthetics stakeholders launched an aggressive lobbying campaign that included outreach to media, Capitol Hill and the White House to have the coverage decision scrapped.
“We feel these policies will suppress medical innovation and limit patient access to life-improving technology,” Reps. Erik Paulsen (R-Minn.) and Anna Eshoo (D-Calif.) said in a joint letter to HHS Secretary Sylvia Mathews Burwell in September.
One of the most troubling changes was a section of the policy which states that amputees who use a cane or crutches instead of putting on their prostheses at any point are defined by the CMS as having a prosthesis that's not medically necessary.
“For the record, using devices that assist in walking such as a cane, crutches or a walker is common and advisable for many seniors and people with disabilities whether or not they use prosthetics,” former Sen. Bob Kerrey (D-Neb.) said in a letter to Burwell. “Medicare's draft (coverage decision) seems to say that If you use a cane or anything that reduces the chances of a fall, we won't pay for your prosthetic limb.”
Advocate groups were pleased with last week's announcement. “This removes the immediate threat that this unwarranted and poorly supported policy posed to patient access to modern prosthetic care,” the National Association for the Advancement of Orthotics and Prosthetics said in statement.