05/18/2023    Ed Davis, DPM

CA Podiatrist Discusses How to Get Insurance to Cover AFOs (Paull Kesselman, DPM)

Many thanks to Dr. Richie and Dr. Kesselman for
their efforts to enable podiatrists to prescribe
AFOs to Medicare patients. This is a necessary and
important service to improve the lives of many
patients who have restricted mobility due to
malfunction of the foot and ankle.

The reimbursement process has been, at times, a
tortuous one. The documentation and forms required
to demonstrate need for AFOs and document proper
device delivery are available on the websites of
many podiatric orthotic labs. Difficulties with
reimbursement persist despite following the rules
for documentation.

Here are some of the challenges.

1.Incorrect interpretation by DMERC Medicare
carriers of the "same and similar" rule. DMERC will
not pay for an AFO of the same or similar type in a
5 year period after dispensation. What does similar
mean? If a patient has lateral ankle instability
and presents to the office with an acute sprain, we
are obligated to provide acute care. That may mean
an ankle brace, CAM walking boot or possibly a
cast, depending on severity. Once the acute phase
is over and the sprain is healed, the patient still
has lateral ankle instability. That may be
effectively treated with an AFO. Provisioning of a
custom AFO for lateral ankle instability involves a
device that is by no means "same or similar" to the
device used for the acute injury. Nevertheless,
DMERC will likely not allow the AFO under the rule.
This needs to be fixed. I feel that it can only be
fixed by creation of a list of devices that are not
same or similar based on medical standards of care
and have Medicare/DMERC agree to that list. Yes,
this is a challenge, but without such an agreement,
the issue will persist.

2. Flawed review process. I have had AFOs, in
several cases that were paid by Cigna, our regional
DMERC carrier, only to be recouped three years
later. Cigna sends a letter stating that a
Recovery Audit Contractor (RAC) did a review and
decided that the devices were not medically
necessary and demands recoupment. We then ask how
that was determined. Cigna replies that the
Recovery Audit Contractor sent us a letter
requesting additional information. We have never
received such letters. Cigna then justifies their
recoupment action on the incorrect assertion that
we failed to answer the non-existent RAC letter.
We appeal. Cigna then asserts that we did not
appeal in a timely fashion, despite appealing
within days, and rejects the appeal.
The DMERC carriers are well aware that most offices
can be discouraged from utilizing AFOs by utilizing
a process that is sufficiently tortuous to deter
solo practitioners with limited resources.

Ed Davis, DPM, San Antonio, TX

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