LCD Myths

What You Need to Know

On September 1st, key changes to the Lower Limb Prostheses LCD and Policy Article went into effect. Since then, we have had multiple discussions with people in the O&P profession that reveal a few key misunderstandings about how the LCD has changed.

Myth #1: Prosthetists Can Now Fit Any K2 Patient with a K3 Foot. The updated LCD does create the possibility of K2 patients receiving K3 feet, but it explicitly limits it to transfemoral patients for whom a K3 knee is medically necessary. In those instances, a K3 foot may be appropriate, but the prosthetist must show how that K3 foot is necessary to facilitate the "safe and proper" use of the K3 knee. The LCD does not create a new avenue for K2 transtibial amputees to receive K3 feet.

Myth #2: Medicare's LCD Changes Automatically Apply to Medicaid. Medicare and Medicaid are separate programs. While it is possible that individual state Medicaid programs could choose to adopt Medicare's LCD changes, they are not required to. Moreover, given the widespread consensus among health policy experts that the Medicaid program may undergo significant changes with the upcoming transition of political power, we believe that most states will refrain from adopting Medicaid coverage expansions in the short-to-medium term.

Myth #3: Medicare Specifically Identified Certain Microprocessor Knees as Suitable for K2 Patients in the LCD. In its public responses to feedback about the draft LCD, Medicare made clear that (a) the PDAC was not responsible for verifying which MPK's were suitable for K2 patients, and (b) the determining factor was whether the manufacturer of an MPK deemed it appropriate for K2 patients.

What this Means for You

First, remember that the updated LCD does not create a new right of access for K2 transtibial patients to receive K3 feet. This would only be appropriate if a clinician could demonstrate that the K2 patient has the potential to become a K3 patient, which is the same standard that has always applied.

Second, if you fit a K2 Medicaid patient with a K3 knee, be aware that this will likely result in a claim denial. Medicaid does not have to adopt Medicare coverage policy and we have not seen any state Medicaid programs update their coverage criteria yet at this time.

Third, if you believe you have a K2 patient who would benefit from a microprocessor knee, check with the manufacturer to verify which MPKs they have deemed appropriate for K2 patients.

To read the updated LCD, click here. To read the updated Policy Article, click here.