Jordynn Gilbert

Limbs Are Not a Luxury

Its one of the oldest sayings out there: you dont know what you have until its gone.
This is certainly true for Patient M (the patient alias Ill be referencing in this paper for Health
Insurance Portability Accountability Act (HIPAA) purposes), a 35-40-year-old registered nurse
and single mother of three young children. Currently on the kidney transplant list, she has been
diagnosed with end stage renal disease, making her eligible to enroll in Medicare before she
turned 65 years old. Due to her kidney failure, Patient M must undergo dialysis three times a
week, making her extremely drowsy and tired afterward. The time needed for dialysis and the
resulting fatigue made being a mother to young children very difficult, but Patient M was
determined to make it work. Unfortunately, Patient M was involved in a car accident
approximately 3 months ago and lost her left leg just above her knee. She has since healed, and
continues with dialysis as she has not found an available kidney. Due to the fatigue caused by
dialysis, she uses crutches along with her prosthesis for her own safety and balance. Playing with
her children is still extremely difficult, but the microprocessor knee and other high quality
components with her definitive prosthesis allow her to more easily interact with them. Patient
Ms functional potential was taken into consideration by her Prosthetist and she will soon be able
to return to her previous quality of life after completing her rehabilitation. Patient M will soon be
able to live her life as she used to, but this expectation may not be true for any future amputees if
the proposed Medicare changes go into effect. On July 16, 2015, the Medicare Local Coverage
Determination (LCD) for Lower Limb Prosthesis (DL-33787) was published and the public was
given a chance to sign a petition against the proposal as well, as write in comments to give their
input. Issued by the Durable Medical Equipment Medicare Administrative Contractors (DME
MACs), the LCD proposals goal was to reduce fraud and prevent Medicare from overpaying for

services. The LCD proposes changes to how prosthetic devices are covered under Medicare,
specifically how patients qualify for devices and what types of devices/componentry available to
them, as well as the entire rehabilitation process for new amputees. Given the magnitude of the
threat, the entire field responded proactively and cooperatively, strengthening the ability of the
field to defend access to O&P care in the future (Thomas). The proposed draft Medicare LCD
will be devastating to all those requiring prosthetic devices.
The first major thing that the proposal wants to change is how prosthetic devices will be
covered under Medicare, focusing first on how patients will first qualify for devices. Before any
evaluation occurs, the LCD would make it so certain health complications in a patients
medical history could immediately reduce their functional level or even disqualify them from
being prescribed a prosthetic device. While some may argue that past complications could
predict a reoccurring problem in the future, limiting the patients ability based on a previous
complication would make it difficult for the amputee to obtain the most practical device to suit
their needs/goals. Also, the draft uses the language health complications which is very broad
and therefore could be interpreted to allow Medicare to save money and not do what is in the
best interest of the patient. After the patients medical history is reviewed, they undergo an inperson medical evaluation by Licensed/Certified Medical Professionals (LCMPs) that then
becomes a part of their medical history. It is during this evaluation that the patient is
prescribed/not prescribed a prosthetic device, and the LCMP can specify sections within that
prescription as they see fit. According to the draft LCD, prosthetist notes will no longer count as
a part of the patients medical record and will no longer be considered a part of that patients
medical team. That also means that the prosthetist will no longer be involved in determining the
functional ability and types of componentry that would be most appropriate for their patients. I

believe that this is a huge injustice for both patients and medical professionals. Physicians are
qualified, as part of the patients medical team, to prescribe prostheses even though they may
only interact with the patient for 15-20 minutes to actually write the prescription. Practitioners
spend the most amount of time with the amputees and have unique, specialized training that can
be valuable to the medial team and patient. Their experience and knowledge of different
prosthetic components can help the medical team determine the appropriate prosthetic
component for each individual patient (Stout et al.). Another change proposed by the draft LCD
is that the patients potential to improve their health and mobility using an appropriate device
will no longer be considered when deciding their functional level (K-level). Therefore, they will
only be evaluated on their current abilities at the time of their in-person medical evaluation. Klevels are determined by observing the patients physical examination, observation of gait, and
self-reporting. I believe that this proposed change may be the most ridiculous of all: Medicare is
asking patients to prove that they can walk without providing them a leg to do so. The in-person
medical evaluation generally occurs shortly after the amputation as the amputee prepares to start
the process of getting their prosthesis. By asking them to demonstrate their abilities at that time
and only judging based on what is observed, their functional level is certain to be much lower
than what would be in their best interest. The idea behind the rehabilitation process is that it
allows patient the opportunity to improve their abilities and K-level, and therefore they should be
judged according to their future potential. Additionally, the new proposal states that any use of an
assisted device (crutches, wheel chair, etc.) will lower the K-level of a patient. This is dangerous
because it does not specify the frequency or length of use; it simply says any. That means that
patients cant be provided with any assistive device, which help ensure their safety during
ambulation, especially as theyre starting out, without having a lasting effect on their K-level.

The functional level of patients is so important because Medicare and other health insurers use
K-levels to justify the medical necessity of certain types of prosthetic components (RosenbaumChou), making this redefinition a huge drawback for the O&P community.
To further address how prosthetic devices will be covered under Medicare, the LCD then
focused on what types of devices and componentry would be made available to amputees. There
are two main adjustments within this category: (1) generic code combinations for feet and ankle
options along with (2) requiring the appearance of a natural gait. First, the LCD will combine
various feet and ankle components currently on the market into combined, generic codes. While
this makes billing easier, it limits the foot and ankle combinations that practitioners can select for
their patients; this severely impacts patient care and the ability for the patient to completely
rehabilitate. Each code the proposal seeks to consolidate represents styles of feet and ankles that
provide a distinct purpose for patients, allowing the prosthetic device to be tailored to a patients
specific functional needs (Stout et al.). By pairing these individual codes, the ability of the
prosthetist to customize the device to the patients needs becomes extremely limited. Also,
amputees may not have the chance to be provided with multi-axle or dynamic feet and ankles,
again limiting their function. Secondly, the proposal requires that amputees must be able to
maintain a natural gait or they will be limited options for lower-functioning
prostheses/components or maybe denied altogether. I believe this is another huge injustice
provided by the LCD; its a vicious circle of events that has no purpose other than to save
Medicare money at the expense of each recipients quality of life. The term natural gait is not
defined within the draft and is a very subjective concept. Even able-bodied individuals do not
walk identically to one another, so expecting an amputee to perform such a task is preposterous.
Additionally, it is irrational to assume that a combination of carbon and metal materials will ever

behave in the same manner as the human body. In the foot alone, there are 52 small, individual
bones that work together to make someones gait natural. A prosthetic foot contains a few
metal bars surrounded by a rubber foot shell. Finally, expecting a patient to be able to achieve
this natural gait without providing them with higher level componentry is not possible. This
proposed cost cutting measure by Medicare has much too high a cost to a persons mobility and
quality of life.
The second major thing that the proposed LCD wants to change is the rehabilitation
process for recent amputees. Currently in the the field of O&P, patients will be evaluated and
given a K-level during their in-person medical evaluations. After this occurs, the componentry of
their definitive (permanent) prosthesis are ordered and fit; multiple sockets are made as the limb
changes naturally. This design allows patients to rehabilitate using the same componentry that
they will be using full-time. Under the new proposal, their process will fundamentally change.
Amputees will be given a preparatory prosthesis with extremely basic componentry to complete
their rehabilitation. They will be given their definitive prosthesis with the higher-quality
componentry upon release. This means that they will rehabilitate using basic technology and will
not learn how to properly use their higher quality components. This is the equivalent of teaching
a child to ride a bike then expecting them to be able to drive a car; just because they both move
forward doesnt mean they work the same way. This permanent prosthetic device could have
significantly different features that would fundamentally change how the person should have
gone through rehab (Stout et al.).

The proposal could affect the 150,000 current amputees enrolled in Medicare, but
advocates worry that its influence could set the standard and the U.S. Department of Veterans

Affairs and private insurers would follow suit. If that happened, the nearly 2 million Americans
without limbs could be affected (Kounang). In Patient Ms case, in order to be gainfully
employed and play with her children, she needs appropriate componentry within her device to
maintain her quality of life. Dan Berschinski, chair of the Amputee Coalition, commented that
every amputee is unique and so are their needs (Alexander). The proposal goes so far into its
cost-cutting measures that it ignores the fundamental principles of those it is trying to service.
The purpose of a prosthetic device is to return the individual to their prior level of function, not
to deter them until they give up. The LCD views prosthetists as suppliers of devices rather than
health care professionals invested in the care of their patients (Alexander).

Bibliography
Alexander, Amanda. "Limb Loss Community Speaks Out Against LCD Proposal at Open
Comment Meeting." O&P News Fall 2015: 8. Print.
Kounang, Nadia. "Amputees Fight Medicare Proposal to Limit Prosthetics." CNN. Cable News
Network, 26 Aug. 2015. Web. 26 Oct. 2015. <http://www.cnn.com/2015/08/26/health/amputeesprosthetic-medicare-rule-change/>.
Medicare LCD Proposal Webinar. Amputee Coalition. National Health Council, 19 Aug. 2015.
Web. 24 Oct. 2015. <http://www.amputee-coalition.org/resources/amputee-coalitionwebinars/medicare-lcd-proposal-webinar/>.
Rosenbaum-Chou, Teri, PhD, et al. "Developing a Reference K-level for Comparison to
Clinically Feasible K-level Assessments." Academy Today: American Academy of Orthotics and
Prosthetics 10.2 (2014): n. pag. Print.
Stout, Susan B., Terrance Sheehan, MD, and Daniel L. Ignaszewski. "Re: Proposed/Draft Local
Coverage Determination (LCD): Lower Limb Prostheses (DL33787)."Message to Stacey V.
Brennan, MD, FAAFP and Andy Slavitt. 5 Aug. 2015. E-mail.
Thomas, Peter, JD. "Prosthetic Limb LCD: How a Genuine Threat Can Motivate an Entire
Field." (n.d.): n. pag. OandP.com. The O&P EDGE, Oct. 2015. Web. 23 Oct. 2015.
<http://www.oandp.com/articles/2015-10_01.asp>.