Monday, May 9, 2016

The Brouhaha around a DMEMAC Lower Extremity Prostheses LCD Revision

In September 2015, the WSJ ran an article on a proposed LCD revision in the DME MAC world, which would change some coverage standards for lower extremity prostheses (see WSJ, here.)  The topic appears again in the May issue of the trade journal Insider CMS (subscription; here).  Inside CMS describes that an Energy & Commerce legislator's effort to "slap a moratorium on the LCD until July 2017" and a House effort to "give CMS more power over local coverage policies in general."   The American Orthotic and Prosthetic Association is also "shopping a bill" on the topic.  The article also describes "a protest from amputees."

An April 28, 2016 letter from four House members to HHS Secretary Burwell is described.  CMS posts that the LCD is on hold pending further workgroup study.

The currently effective lower limb prosthesis LCD (L33787) is here.   A clean copy of the proposed, but suspended, draft LCD DL33787 is here.  A rather messy, autogenerated redline comparing the old and proposed versions is here.  Most of the controversy centers around a functional level classifications of the patient, which governs what level of complexity and function will be covered by CMS in his/her prosthesis.

Other recent LCDs have looked to beneficiary functional level in covering cataract surgery and knee replacment surgery.  As beneficiaries age, their functional level declines.  The Affordable Care Act Section 1182 prohibits drawing a line against Medicare coverage and payment for services like these based on functional level when characterized in QALYs, but not against such a line drawn by the same functional level as long as it is not characterized as QALYs.

An OIG report in 2014 criticized CMS's light-hand approach to LCD monitoring, because it resulted in highly discordant LCDs in some cases (here).   On the opposite side, in recently solicitly comments on MAC management, both CAP and AMP said that mass-action, lockstep LCDs were a very bad idea and that local LCD management was important (for story and links, here.)