Medicare’s Five-Year Rule on Orthoses Is Flawed
By Michael Mangino, CPO, LPO, CPed  On the surface, the five-year
policy on the full replacement of most orthotic devices
promulgated by Medicare is clear-cut and understandable to the
profession. What isn't working is Medicare's policy on denying what
it deems similar items months and even years after the service is
provided.
While the policy may have been instituted as a cost-saving
maneuver to conserve Medicare's limited funds, it is having quite
the opposite effect. Apparently there wasn't enough input allowed
from practicing COs to advise the committee that created this
policy about the harmful effects this would have on Medicare
recipients and O&P providers, as well as the increased Medicare
personnel required to deal with the appeal process.
The problem manifests itself in several ways. The first issue is
that the patients aren't aware that the five-year rule exists. I've
never met a patient who realized that the orthosis he or she was
about to receive is supposed to last for five years because that
patient read about it in Medicare's regulations.
The second issue arises from patient belief patterns. While it's
understandable that permanently disabled patients expect their
orthoses to last, patients who are convinced by their orthopedist
that the orthosis prescribed for the treatment of their condition,
such as a long bone fracture or herniated disc, will be needed as a
short-term rehabilitation device want to believe that the treatment
and rehabilitation process has affected a "cure" in their
condition. They are anxious to discard their orthosis as a bad
memory of a bad injury. These patients believe that it won't happen
again and easily dispose of or misplace their orthoses.
The third issue is hygiene. Some orthoses such as Sarmiento
Style Fracture Braces and some postoperative spinal orthoses are
meant to be worn 24/7 for several months. These orthoses are a
breeding ground for bacteria due to the layers of dead skin, body
oils, and perspiration that have accumulated during the healing
process. Expecting these devices to be reused if there is a
reoccurrence of the condition such as an osteo infection, removal
of surgical hardware, or a herniated disc occurring at another
level in the spine is not a well-thought-out plan by Medicare.
The biggest problem seems to be scaling down from a TLSO to a
lesser, more flexible orthosis or scaling up from an LSO to a more
rigid TLSO for greater immobilization. It's common protocol for
orthopedic spine specialists to try and take a conservative
approach with new patients complaining about spinal maladies such
as stenosis, sciatica, and spondylitis to treat them with
medications and mild- to moderate-control spinal orthoses. If the
condition worsens within the next five years, which is highly
likely when you are dealing with septuagenarians and octogenarians,
we must inform these patients that a custom TLSO or LSO that might
circumvent surgery may not be covered because they have already
received what Medicare might consider a similar device. We also
must tell them that we might not know for months about the outcome
because Medicare's similar device list isn't published anywhere.
Medicare also expects us to tell fixed-income patients that they
must sign an Advance Beneficiary Notice (ABN) to receive a $1,500
custom orthosis that won't be covered because they received a $350
L/S brace four years ago.
I've seen a number of fixed-income patients opt not to get the
orthotic service and use their resources to procure covered
medications to deal with the pain or seek out Medicare-covered
physical therapy treatments. Some go so far as to request
hospitalization because it is covered. Where is the economic sense
in that plan?
Medicare adopted the L-Code system so that it could
differentiate the variety of orthoses that are available to meet
the patient's needs as prescribed by the patient's physician.
Medicare did not adopt the entire list of L-Codes that were
available because it knew that there were some similarities, so it
picked those that were decidedly different from one another. Now
when a patient needs an LSO, the patient is denied because he or
she had received a TLSO within the last five years and visa versa.
The system is flawed. It's creating a hardship for the patient and
transferring the expenses from one Medicare pocket to another.
Michael Mangino, CPO, LPO, CPed, is president of the Bay
Orthopedic and Rehabilitation Supply Company, which has multiple
offices throughout New York State. He is also president of
Prosthetics and Orthotics Management Associates Corporation
(POMAC), a member of the American Orthotic & Prosthetic
Association (AOPA), the American Academy of Orthotists and
Prosthetists (the Academy), and the New York State chapter of the
Academy. 
Table Of Contents - May 2008
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