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David McGill Blogger

New Prosthetic LCD Update

Posted by David McGill | March 21, 2014

All 4 DME MACs have published an updated version of the Lower Limb Prostheses Local Coverage Determination. In a surprising move, the LCD adds the following language regarding code L5969, which Medicare created just a few months ago for the BiOM motor-powered prosthetic foot:

The microprocessor foot or ankle system addition with power assist which includes any type motor (L5969) is not covered because there is insufficient information to demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM Chapter 13. Claims for L5969 will be denied as not reasonable and necessary. [Emphasis added]

What does this mean for you?

There are two key things to consider as a result of this update to the LCD. First, as the new language clearly states, Medicare will deny L5969 moving forward. 

Second, the update is effective retroactively to January 1, 2014. Accordingly, it is theoretically possible that Medicare might seek to recoup any amounts already paid for L5969 this year. 

While this is not completely unprecedented, it is unusual. Medicare's Coding Workgroup created L5969 only 4 months ago and the Pricing Workgroup set a fee for it in late December. 

We will continue to monitor this situation closely and let you know of any updates as new information becomes available.

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