Data, Hard Work, and Unified O&P/Amputee Community Response Yield PARTIAL WIN on Troublesome, Draft LCD for Lower Limb Prosthetics


The White House just announced that CMS “will not finalize” the July 16, 2015 Draft LCD. That may be clarified further when comparable announcement text from both CMS and from the DME MACs are released and can be analyzed.  The White House report appears to confirm the information that AOPA shared at the recent San Antonio National Assembly that O&P could be confident that the July 16 proposed LCD for Lower Limb Prosthetics would not be enacted in anything close to its proposed form.

Unfortunately, there are aspects of this document which raise concerns.  The announcement on the CMS website reports that CMS is going to convene “…a multi-disciplinary Lower Limb Prostheses Interagency Workgroup in 2016…the Workgroup will be comprised of clinicians, researchers, policy specialists, and patient advocates from different federal agencies.”

A “working group” that would include both government officials as well as stakeholders from the public would have been more promising.  The immediate concern is that this is NOT a rescission of the Draft LCD.  Some might see this as following a too frequent government step of “kicking the can down the road.”  AOPA, the O&P Alliance, the Amputee Coalition and others had made clear that complete rescission was necessary because the draft was so completely out-of-touch with patient needs AND because there was no scientific data in the medical literature to support the draft. But the medical literature actually supports the present LCD—not a revision and tightening of requirements for beneficiaries to secure a prosthesis.

We recognize and believe it is a positive step that the draft LCD will not be implemented at this time.  However, we continue to believe that the draft LCD should be rescinded by the Medicare Contractors and that CMS should provide patient and provider stakeholders with a meaningful role in the development of future coverage policies for lower limb prostheses.

There is a principle “if it ain’t broke, don’t fix it.”  Prosthetic spend for Medicare has declined for each of the past 4 years, by a total of 14% since the 2010 high.  Looks like even though they are shelving the LCD, they want to convene a special committee, presumably to craft either a new, or revised LCD.

The foundation and structure within the current LCD is sound but there is an opportunity to improve upon it; there remains a need to establish recognition of the prosthetist’s notes when considering medical necessity. That issue and similar additional requirements to care require continuing efforts to improve beneficiary access.

So, the announcement is a partial win—it means that we will not see the July 16, 2015 draft LCD enacted in its current form. AOPA urges caution in that beyond a White House email, we will need to take the time to examine carefully what the CMS announcement means, to assess any longer term issues/threats, beyond what appears, the near-term assurance that Medicare amputees will not see the kind of immediate degradation in the quality of prosthetic care that the draft LCD would have enforced on them, at least not in the near-term.

AOPA’s leadership and regulatory specialists will review ALL government and contractor communications as they arise, and provide a further analysis once that in-depth review is complete.

The report at this juncture would not be complete without acknowledging with appreciation the hard work of amputees and their O&P providers who supported AOPA, the O&P Alliance and the Amputee Coalition in the all-out effort to stop this LCD from reverting amputees to a 1970’s standard of care.

Read the White House statement.