The American Orthotic & Prosthetic Association (AOPA) said on October 1 that a draft policy governing coverage of lower-limb prostheses would significantly reduce access to advanced prosthetic technology for Blue Cross Blue Shield (BCBS) subscribers in several states. The draft policy was issued by Health Care Services Corporation (HCSC), which operates BCBS of Illinois, Texas, Montana, New Mexico, and Oklahoma.

AOPA’s first concern was that HCSC published the draft policy on September 15 with comments due by October 1. AOPA suggested a minimum 60-day comment period to allow stakeholders adequate time to review the draft and prepare comments. AOPA’s comments were submitted within the 15-day timeframe.

AOPA said the draft policy is “unnecessarily restrictive” and will limit access to advanced technology to BCBS subscribers, especially those classified as limited community ambulators (K2) but who may benefit from microprocessor-controlled prosthetic knees (MPKs). AOPA referenced studies showing MPK use by limited community ambulators reduced the rate of falls and fall-related injuries. AOPA said it believes the HCSC policy would effectively eliminate MPK coverage except for the top percentage of K3 patients.

AOPA’s comments also referenced the June report of the interagency workgroup that was convened to provide a consensus statement on Centers for Medicare & Medicaid Services (CMS) coverage of lower-limb prostheses after the retracted 2015 Draft Local Coverage Determination (LCD) for Lower Limb Prostheses. The workgroup suggested consideration of a National Coverage Determination that would address CMS coverage of MPKs in K2 patients. AOPA stated that restricting access to advanced prosthetic technology was contradictory to the consensus statement and the overall health of BCBS subscribers.

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