05/19/2023    Paul Kesselman, DPM

CA Podiatrist Discusses How to Get Insurance to Cover AFOs (Ed Davis, DPM)

Dr. Davis brings up some very interesting points,
all of which have been discussed ad nauseum for
more than a decade. There have been innumerable
meetings with every health care professional
organization involved in providing all orthotic
devices affected by this policy. I have attended
countless meetings and discussion groups with these
organizations and CMS. Long before that a
significant number of examples of how this broken
policy is counterintuitive to patient outcomes was
presented to the DME MAC and eventually to CMS were
discussed.

The problem with the absurd five-year same or
similar rule, does not square solely with the DME
MAC, but with language contained in the Social
Security Act and the absolute unwillingness of CMS
to change that language. Barking at the DME MAC and
their policy writers and the DME MAC medical
directors is literally barking up the wrong tree!
The DME MAC teams are the dog’s tail while the head
of the dog is CMS! Currently, there is a work
around
https://med.noridianmedicare.com/web/jddme/policies
/dmd-articles/2020/same-or-similar-denials-for-
orthoses-and-the-appeals-process

with the DME MAC Medical Director’s providing a
jointly issued paper in late
Summer 2022 which provides a road map for
documenting the replacement of an existing device.

1) I have found that using that document as the
basis for one’s charting for replacing a device, no
matter whether for a different/replacement device
for the same or different diagnosis or condition in
over 90% of the cases results in successful
appeals.

The other option is to have the patient sign an ABN
and have them pay for the new device. While this
may not be popular or even possible for many
providers to practically obtain, it nevertheless
does exist.

2) The review process by the RAC and other agencies
is no doubt flawed. But this is not limited to DME
and is due to the bounty hunter payment system.
This needs to be fixed!

Long-term, there is pending legislation which has
the potential to resolve the same or similar
problem. If passed, this would change the language
in the Social Security Act and provide relief to
every health care provider effected by this myopic
policy. Podiatrists are not in this alone as the
current state affects every supplier of orthotic
devices including but not limited to spinal,
dental, upper extremity, etc.

All of this and more was discussed during the
recently concluded APMA Committee meetings in
Bethesda last week.

To allude that this is a podiatry problem alone or
that medical associations are not working hard
enough to resolve this issue is clearly wrong!

I can’t disagree with Dr. Davis, in his assertion
that there are simply too many hoops to go through.
Furthermore, “Patients over Paperwork” is clearly a
misnomer.

There is much more to comment on this issue, which
will be included in a full-length feature article
in an upcoming issue of Podiatry Management.

paul Kesselman, DPM, Oceanside, NY

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