The American Orthotic & Prosthetic Association (AOPA) held a press conference warning that, as it and other industry stakeholders predicted, the Draft Local Coverage Determination (LCD) for Lower Limb Prostheses, which was introduced in July 2015, is being used by several private healthcare insurers to deny coverage to beneficiaries with amputations for previously approved medical care and devices. AOPA said that United Healthcare, headquartered in Minneapolis, and Cigna, headquartered in Philadelphia, have been identified as using the nonfinalized Medicare rule to deny coverage. AOPA and six other O&P and amputee-related groups sent a joint letter in February urging Cigna to reverse a late 2015 coverage statement that is being used by the company to deny prosthetic coverage.
Among the concerns of critics of the Draft LCD is that its scientific basis has been debunked by nine researchers whose work had been cited therein by Medicare. They wrote to Medicare that they are “extremely concerned that the [proposed rule to reduce care for amputees] was not based at all on the current literature and science associated with the provision of prosthetic care.”
The Centers for Medicare & Medicaid Services (CMS) has since said it would study the rule further, but did not withdraw it and, in failing to take that step, allowed private insurers to exploit it, AOPA stated, adding that CMS has continued to handle the draft rule in a secretive and nontransparent fashion. AOPA said that CMS denied a Freedom of Information Act request asking for the public comments submitted by members of the public about the draft rule; CMS has not allowed a clear mechanism for additional public, patient, or other stakeholder input to be provided to the committee now handling the draft rule; and CMS has even declined to even identify the names and titles of the individuals who are handling the review process. All are reported to be government employees, and there is no indication whether there are individuals with amputations on this new committee.
Michael Oros, CPO, FAAOP, AOPA’s president elect, and CEO of Scheck & Siress, Chicago, said: “We warned last year that this scientifically unjustified Medicare rule would be exploited by insurance companies if it was not withdrawn…. It is very difficult to imagine any other aspect of American healthcare where millions of people would be denied available and appropriate treatment and devices that can speed their return to the fullest and most active possible life. Even worse, there is no medical or other justification for these unreasonable and inappropriate hurdles that would amount to a return to a 1970s standard of care.”
Two individuals with amputations, Mark Martin, 40, from Portland, Oregon, and Rob Rieckenberg, 37, from Minneapolis, also spoke during AOPA’s press conference regarding initial denials of prosthetic coverage each received from United Healthcare. A streaming audio replay of this news event is available at www.aopanet.org/media/press-releases.