Reimbursement and Insurance Coverage of Prosthetics

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Prostheses are provided by service providers to patients and reimbursed by insurance companies and the federal government as durable medical equipment ([WWW]DME), as defined by the Centers for Medicare & Medicaid Services ([WWW]CMS) under the Healthcare Common Procedure Coding System ([WWW]HCPCS) code set. The subset pertaining to prosthetics are "L-codes." While lists of these codes are [WWW]duplicated elsewhere (with dollar values), they are [WWW]officially released by HHS annually, indexed and in a variety of formats. For example, here is the 2007 [WWW]release of all HCPS codes. While prosthetists usually support the entire device and offer adjustments and follow-up visits, all of the costs for this support must be captured in the single list of L-codes provided in the fitting.

Because of the convoluted nature of this reimbursement structure, individual manufacturers often provide lists of l-codes they suggest may be typically billed for their products (such as those for the [WWW]Flo-Tech System or the [WWW]Utah Arm. [WWW]List servs used by prosthetic service providers are dominated as much by discussions of appropriate l-codes and other billing issues for various products as they are by discussions of unique fitting challenges. There are no regulations defining which devices may be advertised as suitable for billing or definition under particular L-codes, and there are L-codes that have been created for devices from particular manufacturers (e.g., TRS and Otto Bock, see L806 and L6875 [WWW]here). The [WWW]O&P Edge has a good article on L-codes as the traditional bugbear of prosthetists by Judith Philipps Otto, entitled [WWW]L-Codes: What's Wrong? What's Right?.

Insurance companies use the same HPCS code set for prosthetic reimbursement, often paralleling the Medicare rates. Whether or not an insurance company will cover a myoelectric prosthesis, or whether there is a lifetime cap on prosthetic care varies by policy and company. [WWW]The Open Prosthetics Project is routinely contacted by individuals who have exceeded the lifetime cap on prosthetic coverage, or are entirely without coverage. We would like to maintain a list here of resources related to the coverage provided by various insurers, for informational purposes. While the risk of amputation for any reason is small for Americans, the extent of coverage may be an indication of the general quality of coverage provided by a particular insurer. Initial efforts in this area will focus on published policies with respect to powered hand prostheses, although please feel free to add information about coverage limits and legs as well.

[WWW]Aetna
Is the first insurance company that I've discovered who considers myoelectric arm and hand prostheses medically necessary. Their [WWW]Clinical Policy Bulliten is to the point: "Aetna considers myoelectric hand prostheses medically necessary for members with traumatic or congenital absence of forearm(s) and hand(s). Aetna considers myoelectric hand prostheses experimental and investigational for all other indications." The list of L-codes that they cover clarifies the fact that they cover myo arms for all levels of absence with the exception of partial hand amputation, perhaps indicating that they do not cover either that, or external prosthoses. I'm not aware of any myo prosthotic components, although there are partial hand products available.

[WWW]CIGNA
Publishes their coverage position [WWW]online, which states that if prosthetic coverage is available under the policy (subject to the limitations of the policy), that powered (myoelectric) devices are generally not covered. If the particular policy allows powered devices, they are only provided if the patient has the cognitive ability to use the device, can generate a usable signal, and can't use a body powered arm for activities of daily living.

Blue Cross Blue Shield
Has a similar coverage position at the state organizations that I have checked (including [WWW]Empire Blue, Blue Cross Blue Shield of New York and [WWW]Blue Cross Blue Shield of Florida) published [WWW]here and [WWW]here, that includes non-coverage of below the wrist (including partial hand) amputations, a limitation of coverage where wet or electrically noisy environments may be encountered, and, probably most difficult to deal with, where "Standard body-powered prosthetic devices cannot be used or are insufficient to meet the functional needs of the patient in performing activities of daily living (ADL)." Coupled with the statement at the beginning of their summary of the technology, that myoelectric prostheses serve to "restore normal appearance, and to partially restore the function lost," it would seem that these would be difficult conditions to meet.

The Amputee Coalition of America is running a [WWW]campaign to coordinate the efforts of various groups to require [WWW]parity in prosthetic insurance coverage and reimbursement in various states.

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