Lower Limb Prostheses LCD
This is the first in a 6-part series walking through Medicare’s Lower Limb Prostheses Local Coverage Determination. We will go through the LCD section by section.
What You Need to Know:
The first part of the LCD is the Coverage Guidance section. Most of it is boilerplate language that appears in every LCD, no matter what the device/item. However, there are a few key points in this section that are important for you to know:
- It includes a list of additional documents that contain other payment rules. This includes the frequently-overlooked Policy Article accompanying the LCD. The Policy Article for lower limb prostheses contains important and detailed information about several topics not directly covered in the LCD. (We will cover the Policy Article at the end of this series.)
- It states two central coverage requirements that are unique to lower limb prostheses: the patient must (1) “reach or maintain a defined functional state within a reasonable period of time, and (2) be “motivated to ambulate.”
What This Means for You:
First, make sure that you read and understand not only the LCD, but the Policy Article that accompanies it. To find the Policy Article, scroll down to the bottom of the LCD and find the “Associated Documents” section, which has a direct link to the Policy Article.
Second, the requirements regarding reaching/maintaining a defined functional state and establishing the patient’s motivation to ambulate are not optional. The DME MACs frequently deny claims because either your medical records do not cover these points or the physician’s notes fail to corroborate them. Make sure that you therefore incorporate language addressing both of these points into your medical records for every claim and confirm that the physician corroborates your findings in her documentation.