IRR Testing based on Medicare Guidelines
Questions: 10 | Attempts: 137 | Last updated: Oct 13, 2016
73 year old Hispanic male with History of Left AKA in 2006 with purchase of prosthesis in 2006. Patient complaining that prosthesis is not fitting properly he is unable to bend L leg. Patient states he is ambulatory and independent with ADL’s.
Height 70 inches, Weight 198 lbs. Request from contracted Prosthetic/ Orthotic agency received for a new socket. Documentation from the prosthetist indicated that the socket was damaged and this was preventing the patient from bending his leg.
PCP office visit was made one month prior to the request and it was noted that patient was not wearing the prosthesis and was complaining that it was fitting poorly.
Benefit Coverage and Medical Management Guidelines
CMS Local Coverage Determination
A lower limb prosthesis is covered when the patient:
Will reach or maintain a defined functional state within a reasonable period of time; and
Is motivated to ambulate.
A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:
The patient's past history (including prior PROSTHETIC use if applicable); and
The patient's current condition including the status of the residual limb and the nature of other medical problems; and
The patient's desire to ambulate.
Clinical assessments of patient rehabilitation potential must be based on the following classification levels:
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance their quality of life or mobility.
Level 1: Has the ability or potential to use prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands PROSTHETIC utilization beyond simple locomotion.
Level 4: Has the ability or potential for PROSTHETIC ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the PROSTHETIC demands of the child, active adult, or athlete.
A determination of the type of foot for the prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a SACH foot. Other PROSTHETIC feet are considered for coverage based upon functional classification.
An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for patients whose functional level is 1 or above.
A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for patients whose functional level is 2 or above.
A microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for patients whose functional level is 3 or above.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the physician's or prosthetist's files.
A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary.
A determination of the type of knee for the prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the patient. Basic lower extremity prostheses include a single axis, constant friction knee. Other PROSTHETIC knees are considered for coverage based upon functional classification.
A high activity knee control frame (L5930) is covered for patients whose functional level is 4.
A fluid, pneumatic, or electronic knee (L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856, L5857, L5858) is covered for patients whose functional level is 3 or above.
Other knee systems (L5611, L5616, L5710-L5718, L5810-L5812, L5816, L5818) are covered for patients whose functional level is 1 or above.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the physician's or prosthetist's files.
An axial rotation unit (L5982-L5986) is covered for patients whose functional level is 2 or above.
A pneumatic or hydraulic polycentric hip joint (L5961) is covered for patients whose functional level is 3 or above.
More than 2 test (diagnostic) sockets (L5618-L5628) for an individual prosthesis are not reasonable and necessary unless there is documentation in the medical record which justifies the need. Exception: A test socket is not reasonable and necessary for an immediate prosthesis (L5400-L5460).
No more than two of the same socket inserts (L5654-L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time.
Socket replacements are considered reasonable and necessary if there is adequate documentation of functional and/or physiological need. It is recognized that there are situations where the explanation includes but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive patient weight or PROSTHETIC demands of very active amputees.
Select Approve or Deny based on the information contained in the case file.
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