Doug Richie recently posted that there is no
specific Medicare coverage for an AFO for fall
prevention and that physicians should not
dispense AFOs when the obvious clinic indication
does not meet Medicare guidelines.
The Medicare LCD states that to be covered an
item must "be reasonable and necessary for the
diagnosis or treatment of illness or injury or
to improve the functioning of a malformed body
member."
The Medicare Benefit Policy Manual states that
appliances are covered when "used for the
purpose of supporting a weak or deformed body
member or restricting or eliminating motion in a
diseased or injured part of the body."
A recent special report by the Journal of the
American Geriatric Society entitled, "Guideline
for the Prevention of Falls Among Older Persons"
states that the leading risk factors for falls
include: muscle weakness, gait deficits, history
of falls and balance deficits. Podiatrists can
play a valuable role in reducing the likelihood
of falls by using custom AFOs when the support
provided addresses any of these risk factors.
If biomechanical examination determines any of
the following diagnoses to be present, I believe
it quite obvious that clinical indications
demonstrating medical necessity are met and that
that if dispensing custom AFOs, podiatrists can
be confident of satisfying Medicare guidelines:
Muscle weakness (728.87)
Ataxia, muscular incoordination (781.3)
Gait abnormality/ staggering, ataxic (781.2)
Osteoarthritis, localized primary ankle & foot
(715.17)
Arthropathy, unspecified, ankle and foot (716.97)
Pain in joint, ankle, foot (719.47)
Instability of joint, ankle & foot (718.87)
Dropfoot (736.79)
Hemiplegia (438.20)
Josh White, DPM, CPed, Maplewood, NJ,
joshwhite@safestep.net
