Recent Changes for "Reimbursement and Insurance Coverage of Prosthetics" - Open Prosthetics Project Wiki

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2009-10-20 15:18:19

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. [http://lists.ufl.edu/archives/oandp-l.html 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).	+ 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. [http://lists.ufl.edu/archives/oandp-l.html 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 [http://www.cripworld.com/amputee/lcodes.shtml here]). The [http://www.oandp.com/ O&P Edge] has a good article on L-codes as the traditional bugbear of prosthetists by Judith Philipps Otto, entitled [http://www.oandp.com/articles/2008-08_02.asp L-Codes: What's Wrong? What's Right?].

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2009-08-05 14:53:20

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- Blue Cross of Florida - Has similar limitations published -

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2009-08-05 14:53:04

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- [http://www.empireblue.com/ Empire Blue], Blue Cross Blue Shield of New York - Has a similar coverage position published [http://www.empireblue.com/provider/noapplication/f2/s5/t9/pw_ad080374.pdf here], that includes non-coverage of below the wrist (including partial hand) amputations, and a limitation of coverage where wet or electrically noisy environments may be encountered.	+ Blue Cross Blue Shield + Has a similar coverage position at the state organizations that I have checked (including [http://www.empireblue.com/ Empire Blue], Blue Cross Blue Shield of New York and [http://mcgs.bcbsfl.com/?doc=Myoelectric%20Upper%20Extremity%20Prostheses Blue Cross Blue Shield of Florida]) published [http://www.empireblue.com/provider/noapplication/f2/s5/t9/pw_ad080374.pdf here] and [http://mcgs.bcbsfl.com/?doc=Myoelectric%20Upper%20Extremity%20Prostheses 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. + + Blue Cross of Florida + Has similar limitations published

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-22 17:56:19

Differences for Reimbursement and Insurance Coverage of Prosthetics

No differences found!

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-22 17:54:35

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- Is the first insurance company that I've discovered who considers myoelectric arm and hand prostheses medically necessary. Their [http://www.aetna.com/cpb/medical/data/300_399/0399.html 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 level of absence, perhaps indicating that they do not cover external prosthoses. I'm not sure of many conditions for which you might want a myo prosthesis that did not involve the absence of the limb, nor am I aware of any products available that could be used for anything else. But you've got to be careful.	+ Is the first insurance company that I've discovered who considers myoelectric arm and hand prostheses medically necessary. Their [http://www.aetna.com/cpb/medical/data/300_399/0399.html 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.

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-22 17:51:29

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- Aetna	+ [http://www.aetna.com/index.htm Aetna]

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-22 17:50:59

Differences for Reimbursement and Insurance Coverage of Prosthetics

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	+ + Aetna + Is the first insurance company that I've discovered who considers myoelectric arm and hand prostheses medically necessary. Their [http://www.aetna.com/cpb/medical/data/300_399/0399.html 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 level of absence, perhaps indicating that they do not cover external prosthoses. I'm not sure of many conditions for which you might want a myo prosthesis that did not involve the absence of the limb, nor am I aware of any products available that could be used for anything else. But you've got to be careful.

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 18:39:28

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. [http://lists.ufl.edu/archives/oandp-l.html 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 much as 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).	+ 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. [http://lists.ufl.edu/archives/oandp-l.html 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 18:28:21

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- [CIGNA http://www.cigna.com/]	+ [http://www.cigna.com/ CIGNA]

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 17:05:39

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).	+ 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. [http://lists.ufl.edu/archives/oandp-l.html 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 much as 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).
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- 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. [http://www.openprosthetics.org/ 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.	+ 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. [http://www.openprosthetics.org/ 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.
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	+ [http://www.empireblue.com/ Empire Blue], Blue Cross Blue Shield of New York + Has a similar coverage position published [http://www.empireblue.com/provider/noapplication/f2/s5/t9/pw_ad080374.pdf here], that includes non-coverage of below the wrist (including partial hand) amputations, and a limitation of coverage where wet or electrically noisy environments may be encountered. +

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 16:45:17

Differences for Reimbursement and Insurance Coverage of Prosthetics

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	+ 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. [http://www.openprosthetics.org/ 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. + + [CIGNA http://www.cigna.com/] + Publishes their coverage position [http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0233_coveragepositioncriteria_myoelectric_prostheses.pdf 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. +

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 16:29:06

Differences for Reimbursement and Insurance Coverage of Prosthetics

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- 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. 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.,	+ 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. 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 [http://www.cripworld.com/amputee/lcodes.shtml here]).

Reimbursement and Insurance Coverage of Prosthetics

JonKuniholm — 2008-01-09 16:25:33

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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 ([http://en.wikipedia.org/wiki/Durable_medical_equipment DME]), as defined by the Centers for Medicare & Medicaid Services ([http://www.cms.hhs.gov CMS]) under the Healthcare Common Procedure Coding System ([http://www.cms.hhs.gov/MedHCPCSGenInfo/ HCPCS]) code set. The subset pertaining to prosthetics are "L-codes." While lists of these codes are [http://www.cripworld.com/amputee/lcodes.shtml duplicated elsewhere (with dollar values)], they are [http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp officially released] by HHS annually, indexed and in a variety of formats. For example, here is the 2007 [http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=descending&itemID=CMS1188185&intNumPerPage=10 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 [http://1800flo-tech.com/pdfs/LcodesTF.pdf Flo-Tech System] or the [http://www.utaharm.com/lcodes.php Utah Arm]. 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., + + The Amputee Coalition of America is running a [http://www.amputee-coalition.org/absolutenm/anmviewer.asp?a=314&z=20 campaign] to coordinate the efforts of various groups to require [http://www.amputee-coalition.org/advocacy/fact_sheets/prosthetic_coverage.pdf parity] in prosthetic insurance coverage and reimbursement in various states.