Jordynn Gilbert

October 26, 2015

Intern/Mentor G/T 5-6
Annotated Source List
Alexander, Amanda. "Limb Loss Community Speaks Out Against LCD Proposal at
Open Comment Meeting." O&P News Fall 2015: 8. Print.
On August 26, 2015, the four Durable Medical Equipment Medicare
Administrative Contractors (DME MACs) hosted a DME LCD Open Committee Meeting
where members of the limb loss community could share their concerns about the new
proposed Local Coverage Determination (LCD) for Lower Limb Prosthesis. One of the
main things commented upon was that each amputee is different and each amputation
brings a different set of complications. The article then sights two quotes from two
individuals who spoke to this point. Dan Berschinski, chair of the Amputee Coalition
board of directors and lower limb amputee, stated every amputee is unique and so are
their needs. A fellow amputee, Tammy Higginbotham testified that it is hard to find the
right combination for any amputee . . . no two people are alike. Marlis GonzalezFernandez, MD, PhD, Medical director of Outpatient Physical Medicine and
Rehabilitation Clinics for Johns Hopkins Hospital, echoed the theme in stating: the
shape and size of a limb is dynamic. It changes throughout the day, it changes
throughout time and we need to be able to accommodate that for our patients. What we
[as health care providers] want . . . is the ability to prescribe the right device for the right
patient and do that at the right time and make sure that they do reach the full potential
that they have. This LCD will not allow us to do that anymore. Next, the article notes
the most fervent speech of the meeting, spoken by Charles H. Dankmeyer Jr. (CPO),
president of the American Orthotics & Prosthetics Association. He said, Have you
started the clock yet [referring to his time limit for speaking]? Why dont you turn it back.
You folks have proven you know how to do that very well. He also called the LCD
absolutely insulting and mean-spirited, saying the barriers created for amputees by
the proposal are intentionally designed to wear people out so they would just give up.
The article then states that one of the most mentioned concerns was the idea that the
LCD views prosthetists as suppliers of devices rather than health care professionals
invested in the care of their patients. The article ends with a quote from Reggie
Showers, an amputee who works as a motorcycle racer and snowboard instructor: My
story is one of many here, many inspirational stories . . . I cannot help but think of all the
stories that will never be shared if this proposal passes and future amputees are not
given the lower limb devices that they need and deserve to live a better life. A
photograph of many of the amputees present at the open meeting was included.
This article is useful to me because it demonstrates that the current LCD draft
proposal is in fact a large problem. My research wouldnt mean anything if it only
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mattered to me; this article shows just how many people it affects. It is also important
because it shares the opinions of professionals who are highly ranked in their fields; it is
important to understand the true impact the new proposal will have, not just what
Medicare has projected. The quotes are also very good and I will most likely use one or
two of them in my paper. The most interesting thing about this article, however, that the
most passionate speech was delivered by none other than Charles H. Dankmeyer Jr.,
the founder of Dankmeyer Inc., the location at which I am currently interning,
"Amputee Coalition." Amputee Coalition. National Health Council, n.d. Web. 1 Oct. 2015.
<http://www.amputee-coalition.org/>.
Established in 1986, the Amputee Coalition is a nonprofit, nationwide, voluntary
health organization dedicated to ensuring that no feels alone and that amputees and
their families have the resources they need to recover, readjust and live life fully with
limb loss/difference. Their mission is to reach out to and empower people affected by
limb loss to achieve their full potential through education, support and advocacy, and to
promote limb loss prevention. The website offers a variety of resources, including
articles and links to the current Medicare LCD proposal. They also offer resources
based on amputation level, specific topics or groups, pain management, etc. The
organization additionally offers information of support groups, advocacy/awareness
programs, and much more. They also provide information about their magazine,
inMotion.
Specifically suggested to me by my mentor, this resource is extremely valuable
to me for several reasons. It provides me with a bounty of current information and
articles that explain up-to-date issues in the field. Additionally, it is a way to find events
and different avenues to get involved, whether it be through donation or signing up with
health care providers that better suit amputees or a variety of ways to conduct research.
It is an extremely valuable resource to me in particular because the website takes
current issues in the field and explains them in a way that someone without an
extensive education in the field can understand. It takes the technical jargon that would
otherwise be presented with the new Medicare LCD proposal and enables me to easily
understand it and it highlights the key points the community should be aware about. The
organization makes it incredibly easy to get involved.

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"AOPA." American Orthotic & Prosthetic Association. N.p., n.d. Web. 9 Oct. 2015.
<http://www.aopanet.org/>.
Established in 1917, the American Orthotic & Prosthetic Association has worked
for the favorable treatment of the O&P business in laws, regulation and services; to help
members improve their management and marketing skills; and to raise awareness and
understanding of the industry and the association. Their website offers a bounty of
resources, from coding information placed by the government to stories of amputees.
They also provide up-to-date research and video seminars explaining current issues.
This resource is extremely beneficial to me as it is the website of the most
renowned association in Prosthetics and Orthotics. The information on Medicare and
current regulations is important because it demonstrates the baseline for which the rules
will change. Their current research is extremely beneficial for my own knowledge of the
progress the field is making, but not necessarily for my paper. Finally, the webinars and
explanations are the most valuable research that I have found thus far. They explain
extremely complex, jargon-intensive ideas and explain them so the average person can
understand them. This simplifies my understanding of the issue and allows me to write
my paper with a complete understanding of the current issues.

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Klein, Tim, RN. "Sponsor's Editorial: Risk Management Tips for Orthotic and Prosthetic
Professionals." Academy Today 10.2 (2014): n. pag. Print.
This article basically explains the two types of liability claims that are typically
brought against O&P practitioners: Product liability claims and professional liability
claims. A product liability claim involves manufacturers, distributors, suppliers, or
retailers for manufacturing defects, design defects, and failure-to-warn defects that are
responsible for causing injury. A professional liability claim requires evidence that a
healthcare provider owed a duty of care and that they breached that duty of care. Next,
it states that the most common injury allegations are results of falls, fittings, defective
products, and complications. Finally, the article suggests nine ways to help reduce
practitioner's exposure to liability claims. First, they can review the Manufacturer and
User Facility Device Experience (MAUDE) database where they can view multiple
reports and reviews, which may indicate a major problem with particular devices.
Second, they can obtain the patients informed consent prior to treatment to further
protect themselves if an adverse result occurs and to also make their patients aware of
risks. Third, they can assess the patients risk of falling and consult a physical therapist
for assistance and additional gate training as needed, along with ensuring the device fits
properly. Fourth, explaining and handing the patient a written copy of instructions on
how to properly use the device should be administered and written at about a fourthgrade reading level. Fifth, practitioners should assess residual limb sensation because
patients with diminished sensation may be unaware of blisters, abrasions, or other
cutaneous issues, delaying seeking medical care and increasing their risk of infection.
Sixth, ensuring that you understand the intended use for the device can help the
practitioner better meet the needs of the patient and warn against improper use.
Seventh, inspecting the device during each visit, particularly load-bearing devices,
should be conducted regularly and heavily documented. Eighth, a good practitioner
reviews their systems and processes before placing human blame. Finally, the article
lists the things that are particularly important to document about consultations and how
to properly correct a medical record.
This article is useful to me in my professional career as a prosthetist and orthotist
because it helps me become aware of the dangers I may face. However, it is not useful
to me in any other way as it does not have to do directly with insurance policies and
what they do and do not cover for their patients.

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Kounang, Nadia. "Amputees Fight Medicare Proposal to Limit Prosthetics."CNN. Cable News
Network, 26 Aug. 2015. Web. 26 Oct. 2015.
<http://www.cnn.com/2015/08/26/health/amputees-prosthetic-medicare-rule-change/>.
A CNN report begins by explaining that the new Medicare proposal will create
more stringent requirements to obtain advanced prosthetics, reduce the role of the
prosthetist who creates and maintains prostheses, and eliminate some of the universal
codes that all providers use to cover prosthetic care. They then emphasize that initially,
the new proposal will only affect the 150,000 amputees currently enrolled in the
Medicare system; however, advocated fear that private insurers and the VA (U.S.
Department of Veteran Affairs) will soon follow, affecting approximately 2 million
Americans. They then offer a personal story to demonstrate that the current Medicare
system covers what people need to live full lives and, if the proposal went through, a
father may not be able to do something as common as playing with his children. When
CNN confronted about why there was an effort to change the policy, the Centers for
Medicare and Medicaid Services stated that the decision came from the Medicare
contractors who administer payment for prosthetic care (all companies having ties with
private insurers). CNN then reached out to the leading contractor behind the proposal,
CGS Administrators (owned by BlueCross BlueShield of South Carolina), but received
no comment. The main evidence that appears to support it comes from a 2011 audit
done by the Department of Health and Human Resources who found a 27% increase on
spending on lower limb prosthetics between 2005 and 2009, despite the number of
Medicare beneficiaries decreasing. Tom Fise, executive director of the American
Orthotic & Prosthetic Association (AOPA), called the date outdated and stated that it
was not reflective of the real picture: total prosthetic care spending decreased 13% from
2010 to 2013. During the open hearing, Bob Kerrey (former Nebraska Senator and
amputee) stated that This is as stupid a rule as Ive ever seen. This rule completely
ignores whats going on with amputees. Another fear following the new proposal is that
amputees will no longer have access to the advanced technology available on the
market because insurance will stop covering it; this in turn could stall development of
such technology all together. Adrianne Haslet-Davis, a dancer and Boston Marathon
bombing survivor, stated that these are human body parts and that if the changes go
through, it would deny what I believe are human rights to walk, dream, and be
unstoppable. The new proposal will return amputees to a basic level of care, and
private insurers will follow because it the government doesnt cover, they have no
reason to. Finally, the article emphasizes that getting the right fit is something a
prosthetist specialises in. The fit of a prosthetic device is extremely important to the
comfort and function of an amputee; its not one size fits all. Brian Mast, a soldier who
lost his leg in the Army in Afghanistan, offered a quote highlighting the needs of
prosthetists: "I've had numerous doctors, even after looking at the prosthetic leg,
they've had to ask me 'Are you an above or below the knee?' Doctors are nowhere near
as well proficient as prosthetists.
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This article does a nice job of summarizing the main points of the O&P
community from a non-technical standpoint. The ideas are very general and basic and
do not go into detail, but they are easy to understand for the average citizen. The
statistics at the beginning are shocking because they put into view just how many
people will be affected by the proposal; by sharing that it will not only affect those
covered by medicare, more people are likely to get involved. Next, the article shows that
there is no sound evidence behind their changes, but it is simply a cost-saving strategy;
the data from the audit and that offered by Tim Fise could be very useful in my paper.
CNN then makes the story relatable by saying that the advances technology of current
prosthetic devices allows people to live their lives and be unstoppable like everyone
deserves to be. Lastly, they touched on the idea that prosthesis are not simply a one
size fits all concept, and that prosthetists are the only ones who can make it perfect.
The fit of a prosthetic leg is vital for the comfort and functionality of a patient.

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"Medicare for People With Limb Loss." Amputee Coalition. National Health Council, May 2015.
Web. 23 Oct. 2015. <http://www.amputee-coalition.org/resources/medicare-for-people-withlimb-loss/>.
Offered by the Amputee Coalition, this fact sheet helps amputees understand
their options under Medicare. Broken down into eight sections, section one defines
Medicare as a federally funded health care coverage for people who are 65 years old
or older, certain younger people with disabilities, and people with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called
ESRD). It then breaks down the two main Medicare plans: Original Medicare (Parts A
and B) or Medicare Advantage Plan (Part C); it also explains additional coverage
options, such as Medicare prescription drug coverage (Part D). Section two focuses on
what coverage Medicare offers for people with limb loss. Medicare Part B covers
orthotics, artificial limbs and eyes, arm/leg/back/neck braces, orthopedic shoes, and
therapeutic shoes/inserts for people with diabetes; all items are covered as durable
medical equipment (DME). Everyone is eligible, and they pay 20% of the Medicareapproved amount; based on the type of equipment, they may need to rent it, buy it, or
they may be given the choice. It cautions users to make sure that their doctors and
DME suppliers are enrolled in Medicare; if they arent, Medicare wont cover it. Section
three discusses how to enroll in Medicare: some people are automatically enrolled,
others must manually sign up. Individuals are automatically enrolled in Medicare Parts A
and B if they receive benefits from Social Security or the Railroad Retirement Board, are
under 65 years of age with a disability, suffer from ALS, or live in Puerto Rico and
receive benefits from Social Security of the RRB. Section four mentions the open
enrollment period, a time when individuals and families can enroll in health insurance
coverage. Section five demonstrates the tax penalties for not having health insurance
by listing the annual cost, per year; in 2014 it was approximately 1% of the household
annual income (up to $285 per family), but in 2016 grew to 2.5% or the household
annual income (up to $2,085 per family). Section six explains the three ways to file an
appeal with Medicare when they deny a payment for a prosthesis. Individuals can fill out
a Medicare Redetermination Request Form, send a request to the company that
handles claims for Medicare, or send a written request to the claims office. It is
extremely important that patients list their Medicare number on all documents and keep
a copy of everything they send. Section seven compiles all the links found throughout
the fact sheet into one place for easy access (Part B application, Medicares Eligibility
and Premium Calculator, etc.). Finally, section eight sights additional resources, such as
a Putting Patients First cost calculator to estimate out-of-pocket costs.
While this fact sheet doesnt explain the new Medicare policy, it explains
Medicare itself and everything it entails. The most important section is section two,
which discusses what Medicare currently covers, how it covers it, and how patients
must pay for it. Orthotics are only covered if the supplier is enrolled in Medicare,
orthopedic shoes are only covered if they are a necessary part of a leg brace, and
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therapeutic shoes/inserts are only covered for people with diabetes who have a severe
foot disease. The face that Medicare pays for different kinds of DME in different ways
(requiring some renting, buying, or a decision) is a bit concerning because there is no
standard method of determination. Another concern is that the policy is very specific
that Medicare will only cover an individuals DME if their doctor and DME supplier are
enrolled in Medicare; this leaves a lot of room for error if the patient isnt informed.

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Medicare LCD Proposal Webinar. Amputee Coalition. National Health Council, 19 Aug. 2015.
Web. 24 Oct. 2015. <http://www.amputee-coalition.org/resources/amputee-coalitionwebinars/medicare-lcd-proposal-webinar/>.
Dan Ignaszewski, Director of Government Relations with the Amputee Coalition,
presented a live webinar that lasted approximately an hour; the power point was
available on the Amputee Coalition website. He outlined the impact of the draft proposal
on lower limb prosthetics. First, the presentation discussed what the draft LCD proposal
actually is. Drafted by Medicare Administrative Contractors (MACs), its goal was to
reduce fraud abuse and prevent medicare from overpaying for services. The proposal
changed how prosthetic devices were covered under medicare, focusing on how
patients qualify for prosthetic devices and what types of devices or components are
provided for amputees. It also proposed changed to the rehabilitation process for new
amputees. After noting that he will go into further explanation, he highlighted the main
reasons individuals should be concerned with the new proposal (all will be discussed in
further detail later). First, the new proposal states that functional potential will no longer
be considered when determining the K-level of a patient. This is concerning because at
an amputees initial evaluation, theyre certain to be at a lower functional level than what
they could be at. It is important that they are able to improve their abilities and increase
functional levels, and therefore they should not be judged on their current functional
level (upon evaluation), but instead on their future potential. Secondly, the use of
assistive devices would automatically limit an amputees functional status. Third, feet
and ankle options would be limited because various feet and ankles would be combined
into generic codes; as a result, amputees may not have access to multi-axle or dynamic
feet or ankles. Fourth, amputees may be required to attain a natural gate (which is not
defined in the proposal, or entirely reasonable for someone with a prosthesis), or else
receive limited options for lower-functioning devices or even denial of a prosthetic
device, itself. Fifth, certain health complications in your medical history could disqualify
an individual from a prosthetic device, or simply reduce their functional status. This
would make it difficult for an amputee to obtain the most practical device to suit their
needs. Lastly, the rehabilitation process for new amputees would be fundamentally
altered and would force new amputees to rehabilitate on a device with basic
componentry. Ignaszewski begins a more in depth evaluation of the new proposal by
examining the current vs. proposed definitions of functional levels (K0 - K4). The current
definitions use the word potential, but the proposed definitions do not. Most
horrendously, the proposed definitions contain specific references to the use of assisted
devices. For example, the use of a walker or crutches while using a prosthesis results in
a K1 classification, and the use of a cane while using a prosthesis results in a K2
classification. K3 and K4 levels of classification does not require the use of any mobility
assistive equipment such as canes, crutches, walkers, or wheelchairs. This is a major
problem because the majority of amputees, regardless of their functional level, may
need to use an assisted device to maintain mobility, for example, when they don't have
access for their prosthetic leg and need to get around. This new proposal of the
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classification of functional levels is dangerous for many reasons. First, potential needs
to be considered in order to help the amputee succeed and progress as smoothly as
possible. Second, amputees need to be able to increase their functional levels as their
abilities progress; the components need to be able to be adjusted along with these
changes. And finally, if not most importantly, functional levels should not be judged
based upon what kind of assisted device the amputee is using the day they are
evaluated; this is not representative of what will be best for them in the future. The main
idea of this change is that amputees need to able to receive the most appropriate
device at the most appropriate time; the new definition of functional levels does not
allow this to occur. He then moves on to talking about the problems surrounding the foot
and ankle policies. The foot and ankle components of prosthesis are important when it
comes to the stability of the amputee and their safety in regards to falling; if patients
dont receive the most appropriate components for their needs, it could be a safety
hazard. Medicares proposal would consolidate several feet and ankle codes into a
single code. While this may seem like an adjustment aimed toward the billing aspect, it
has the potential to severely impact which feet and ankles amputees have access to.
When several feet and ankles are combined into one code, the most cost-effective
(cheapest) component within that code is usually sent to the amputee; this may not be
the most appropriate option. Additionally, it makes it nearly impossible for practitioners
to establish the idea foot and ankle pair for the patient, as a different can come every
time they order the components with the generic code. The proposal will also limit K2
patients to fixed ankle-feet. Currently, this functional level had access to multi-axle
ankles and dynamic response feet; under the new proposal, only K3 and K4 level
patients will be eligible for these components. This is a concern because K2 patients
could greatly benefit from these devices, but not theyre not being given access to them.
After discussing the feet and ankles, Ignaszewski moves on to the new proposal
regarding vacuum sockets and liners. First, the proposal may make it more difficult to
receive custom fabricated socket inserts, now making it an exception to receive a
custom insert/roll-on liner and would give most patients a generically shaped one. This
is distressing because the determination of the most appropriate liner type needs to be
made by the amputees medical team, and they need to have access to all of the
available materials. As a result of the increased difficulty, the proposal discourages
prosthetists from seeking custom liners for their patients even if it would be the best
option for their needs. Second, the proposal would eliminate suction suspension
systems for an option for K1 level patients. This is extremely troubling because the
socket is an extremely important, if not the most important, piece of the prosthesis
because it is responsible for the amputees overall comfort and ultimately allowing them
to keep their leg on. This point limits the functional ability of what the amputee can
achieve; all suspension options should be available in order to provide the best care.
Third, the proposal would eliminate elevated vacuum sockets for all patients, though it is
unclear whether Medicare was referring to only battery suction or also manual suction.
Finally, the proposal would eliminate cushioned (gel) liners for patients who also receive
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a molded distal cushion. This is an issue because the two are not independent; most
patients who require one would require the combination of the two to provide the best
care for what they need. After that, the discussion moves into the protocol for in-person
medical evaluations and functional status determination. The new proposal requires an
in-person medical evaluation by a Licensed Certified Medical Practitioner (doctor,
therapist, etc.). Although this is not a huge change, the proposed policy excludes
prosthetists from the list; this is a huge issue because prosthetist involvement is crucial
in order to help the patients rehabilitation go smoothly. The new proposal also may
reduce or limit functional status if an amputees medical record includes references to
cognitive, neuromuscular issues, or cardiopulmonary issues. Although it does not
specify limitations or denial based on these conditions, the fear is that patients will be
wrongfully penalized if those things are mentioned in their records. The Amputee
Coalition stresses that functional levels should be based on the patients overall health
status and their physical abilities. The new proposal could result in a patient receiving a
lower status of componentry simply based on their records (for example, high blood
pressure) and receive an inappropriate care. The last major area of the proposal that
Ignaszewski references is the redefinition of the rehabilitation process for new
amputees; specifically, there are changes to the immediate, preparatory, and definitive
prosthesis. In regards to immediate prosthesis, the proposal is not much of a concern
as it states that amputees will receive their post-operative right after surgery to get them
mobile. The major concerns are with the preparatory prosthesis, and its impact in regard
to the definitive prosthesis. The proposal redefines a preparatory prosthesis as a basic
device that does not take into account functional status; the amputee must first
complete a rehabilitation program on this basic device to get their definitive prosthesis.
This is an enormous problem for two main reasons. First, the preparatory prosthesis,
according to the Amputee Coalition, should really be a definitive prosthesis that will only
need a socket adjustment later after limb atrophy has plateaued. The one amputees
would receive under the new proposal would not meet their needs whatsoever because
of the required basic componentry. Second, the need to first complete a rehabilitation
program using the basic device creates a situation where the amputee goes through
training on a less complex leg than their definitive prosthesis. It is important for
amputees to rehab using the leg they will use in the future so they can learn how to
properly and safely use it. Ignaszewski compares this to teaching an individual to ride a
bike then expecting them to be able to operate a car; its irrational. The proposal
redefines a definitive prosthesis as a permanent prosthesis based on their functional
level. This is a problem because by that stage, the amputee would be receiving their
device too late, and would not have the use of a rehabilitation program to learn how to
properly use it. The webinar concludes with the Amputee Coalitions recommendations
to the policy: Medicare should rescind their draft proposal and thoroughly revise it to
include changes to the concerns outlined above, input from applicable parties, and to
better reflect the current path of amputee care. The Amputee Coalitions main concerns
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are then listed at the very end, along with instructions and links concerned parties can
use to make a change and have their opinions heard by those drafting the proposal.
This is hands down my most important source. The Amputee Coalition does an
amazing job at simplifying the drafted proposed changes to their policy in a way that
people without extensive education can understand. It outlines the major changes,
diving into the more specific changes and specifications later. They also add their input
as to what they think the proposal needs to say in order to provide amputees with the
most appropriate device at the most important time.
Newhardt, Jed, CPO. Personal interview. 6 Oct. 2015.
Jed Newhardt is a Certified Prosthetist Orthotist, who has been with Dankmeyer
for two years. While in high school and exploring potential careers, Jed stumbled
across a newspaper article about amputees, which triggered his interest in the field. His
interest grew into a passion while he volunteered and later worked as an apprentice at a
local prosthetic and orthotic facility where he grew up in Bethlehem, Pennsylvania. He
eventually made the decision to travel to Seattle, Washington to attend the University of
Washington where he received his BS in Prosthetics and Orthotics. His prosthetic
residency was completed at the Rehabilitation Institute of Chicago and he completed his
orthotic residency at Dankmeyer. He has always enjoyed working with his hands and
interacting with patients. Outside of work, Jed can be found exercising or spending time
outdoors. He enjoys mountain biking, snowboarding, and working on his motorcycle.
Mr.Newhardt is vital to my internship as well because he acts as my Co-Mentor
(to Mrs.Reedy) on Fridays. He is important in similar ways as Mrs.Reedy; every
practitioner has their own, unique style of treatment and assessment as well as
techniques that theyve found to be useful. However, he is a great asset for me to use
when examining my education path. As a recent Graduate School graduate, he is
familiar with the process of obtaining a degree in Prosthetics and Orthotics and has
good insight as to what the program is like.

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Reedy, Mary, CP. Personal interview. 6 Oct. 2015.

Mary Reedy is a Certified Prosthetist, who has been with Dankmeyer for sixteen
years and is from Bel Air, Maryland. Early, she wanted to be a robotic engineer and
work with animatronics at Disney World. While researching other engineering options at
college, she came across the field of prosthetics. She contacted Joe Delorenzo at
Dankmeyer to learn more about the field and spent two summers volunteering at
Dankmeyer. She went on to complete her BA in Human Services Counseling from
Metropolitan State University in St. Paul, Minnesota, while consecutively completing her
Associate of Arts in Prosthetic Technology. She stayed on in Minnesota at Century
College in White Bear Lake, to complete her Diploma in Prosthetic Practitioner
Advanced Specialty. Mary returned to Baltimore, and to the place which inspired her
career path, to complete her prosthetic residency at Dankmeyer. Outside of the office,
she enjoys hiking and camping with her family.
As my mentor this year, Mrs.Reedy is my most important source as she gives me
access to this entire experience. My understanding of procedures and processes are
largely based on what she communicates to me. I am mainly influenced by her, as well,
on how to assess patients and ways to go about solving problems during consultations.
Her enthusiasm toward her career has only made me that much more certain that this is
that path that I would like to pursue, as well.

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Rosenbaum-Chou, Teri, PhD, et al. "Developing a Reference K-level for Comparison to

Clinically Feasible K-level Assessments." Academy Today: American Academy of Orthotics
and Prosthetics 10.2 (2014): n. pag. Print.
This article explains the Medicare Functional Classification Level (MFCL), a fivelevel classification system used to describe the functional level of persons with
amputations. It then lists out the classifications of each K-level, ranging K0 (no
ambulation) to K4 (unlimited ambulation and use of prosthesis for recreational pursuits).
It then explains that clinicians decide the K-levels of their patients based on patient selfreport, physical examinations, and observation of gait. However, patient self-report is
dangerous because it is heavily relied on but can be easily miscommunicated or
exaggerated. The K-levels 0-4 are then broken down into a chart that is specific to the
MFCL definition for clarification. The article next explains that they conducted a study by
collecting data using GPS devices and activity monitors. The table reported how many
steps each K-level classifies as approximately per day, peak steps within a week, peak
cadence (steps per minute; walking rate) within a week, and their ability to transverse
environmental barriers (curbs, stair, hills) within a week.
This article was extremely helpful because it explains what K-levels are and how
clinicians mainly determine them. It defines the exact parameters of each K-level as
defined by the MFCL. This is useful because in order to justify the need for upgraded
and more advanced componentry, you must medically justify your patient to be at a
certain K-level. If a clinician accomplishes this, Medicare will pay for the patient to return
to their normal standard of living, as defined by their particular K-level. What follows at
the end of the article, the advanced breakdown of number of steps the average
amputee at each K-level takes each week, is only important in predicting how quickly
componentry will need to be replaced. Every time it needs to be replaced, clinicians
must file with the insurance companies so they will pay for it by, once again, proving it to
be medically necessary.

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Thomas, Peter, JD. "Prosthetic Limb LCD: How a Genuine Threat Can Motivate an Entire
Field." (n.d.): n. pag. OandP.com. The O&P EDGE, Oct. 2015. Web. 23 Oct. 2015.
<http://www.oandp.com/articles/2015-10_01.asp>.
Seldom does a threat at large as the proposed/Draft Local Coverage
Determination (LCD) for Lower Limb Prostheses (DL-33787) issued by the Durable
Medical Equipment Medicare Administrative Contractors (DME MACs) confront the
O&P community. Not only would it affect O&P practices, but also practitioners,
manufacturers, suppliers, and especially patients. This article gives an overview of all
the events thus far that have transpired due to the entire O&P field working in
coordination with one another toward rescinding the proposal. First, the article gives an
overview of the LCD, defining it as an a complete rewrite of Medicare coverage,
coding, and payment policy for lower-limb prostheses. It also notes that the most
disconcerting aspect is that its based on virtually no evidence, which is the primary
requirement for development of an LCD. Then, it discusses that the LCD impacts all
three of the current O&P priorities: linking provider qualifications with the right to bill the
Medicare program for custom orthoses and prostheses, finally regulating prior
authorization for durable medical equipment, prosthetics, orthotics, and supplies
(DMEPOS), and establishing that the clinical notes of appropriately credentialed
prosthetists and orthotists should be considered part of the Medicare patients record for
purposes of determining medical necessity. Given the magnitude of the threat, the
entire field responded proactively and cooperatively, strengthening the ability of the field
to defend access to O&P care in the future. First, a White House We the People
petition, launched by the National Association for the Advancement of Orthotics and
Prosthetics (NAAOP) on July 31, asked President Obama to rescind the Draft LCD. The
success of achieving 100,000 signatures in 30 days has obligated the president to
respond to the petitions request; the White House has until mid-October to issue a
formal response. On August 26, the DME MACs, drafters of the LCD proposal, held a
public hearing for the public to comment on a set of policies. There was so much
interest in attending that the venue had to be relocated to be able to hold hundreds of
people, phone lines had to be utilized, and the speakers had to be capped at 50. The
comments came from across the O&P spectrum, including comments from amputees,
physicians, practitioners, therapists, and many more; the hearing offered many
compelling reasons to dramatically modify the Draft LCD. Immediately following the
public hearing, more than 100 amputees rallied in protest outside of the U.S.
Department of Health and Human Services (HHS), which oversees CMS and the DME
MACs. There was also a high-level meeting between HHS and CMS leaders, as well as
eight representatives from the O&P community, five of whom were amputees. As the
rally continues within earshot and serious concern was emphasized, Andy Slavitt, CMS
Acting Administrator, and Patrick Conway MD, CMS Chief Medical Officer, promised a
thorough review of the policy. They also stated that the policy was drive on evidence, as
the CMS is prohibited from considering cost savings when developing LCDs. The
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heightened attention pushed advocates to submit comments to the DME MAC medical
director; the O&P Alliance submitted a 138-page detailed response to the Draft LCD on
behalf of its five member organizations. Although they will not release the number, it is
clear that the Medicare contractors receives thousands of letters from advocates spread
wide across the O&P community. After this, the AOPA sent a letter requesting evidence
that supported the Draft LCD. The released bibliography contains citations that were not
considered evidence-based medicine, and those that did meet the criterion were 20,
30, and, in one case, 50 years old. Nearly 400 television newscasts and newspaper
articles throughout the country picked up on the issue, and the AOPA and the Amputee
Coalition hosted a press briefing to accelerate media attention. Former senator Bob
Kerrey, a transtibial amputee, volunteered his voice and time for the cause, becoming
an unpaid spokesman. The need to rescind the Draft LCD was highlighted when the
United Healthcare announced that it no longer covered elevated vacuum technology.
Without an outright rescission of the proposed policy, the O&P field can expect more of
this to occur. The O&P community, therefore, has no choice but to remain vigilant in
opposing the Draft LCD.
This article is very important for my research because it gives meaning to the
cause. While it is important to understand the changes that the Draft LCD proposes, it is
also important to see that the entire O&P community has rallied together in protest. The
numerous avenues taken to gain attention show those who may be uninformed just how
influential the changes can be. It also emphasizes that this is not just an attention
scandal, but a very influential problem that needs to end. Furthermore, it demonstrates
that the government had absolutely no reason to do this other than to take cost saving
measures, and that it is very difficult to change policy.

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"Update: AOPAs Analysis of Proposed Lower Limb Prosthetic Policy."American Orthotic &
Prosthetic Association. AOPA, 21 July 2015. Web. 23 Oct. 2015.
<http://www.aopanet.org/2015/07/update-aopas-analysis-of-proposed-lower-limb-prostheticpolicy/>.
This article lists the key issues stated in the joint proposal from the four DME
MACs and the changes to the Local Coverage Determination (LCD) relating to
reimbursement for lower limb prosthetics. First, it creates clear definitions between
immediate, preparatory, and definitive prostheses. It notes that restricting delivery of a
definitive prosthesis until completing a rehabilitation program is most likely not in the
best interest of the patient. It then states that the three prosthesis mentioned above are
all inclusive, and separate components billed with prosthetic base codes will be denied
due to medical necessity. Third, all additions, adjustments, modifications, and
replacements will not allow for socket or component changes on preparatory prostheses
for 90 days following delivery. Next, requirements that patients must have a healed
incision site and must be starting a rehabilitation program will create additional
documentation hurdles for prosthetic providers, further delay patients care. For the
initial definitive prosthesis to be covered, amputees must successfully complete a
rehabilitation course and undergo an in-person medical evaluation. Additionally, custom
fabricated socket inserts will no longer be easily accessible. Suction suspension
systems will also no longer be medically necessary for patients with a K1 functional
level. Consolidation of foot and ankle codes will severely limit the choices amputees
have access to, and will prevent them from receiving the best care. Prosthetic skins will
only be covered if patients are regularly exposed to harsh environmental conditions or it
they require additional protection for any reason. The requirement for patients attain a
the appearance of a natural gate prevents coverage of a prosthesis that is otherwise
functional. Also, any documentation of cognitive, cardiopulmonary, and neuromuscular
control in a patients medical record can influence their functional level, even if it is not
evident when observing the individual. If the patient utilizes, or if the patients records
show that Medicare has paid for, any form of mobility aid (cane, crutches, walker, etc.)
access to higher quality prosthetic components will be severely limited, regardless of
your functional capabilities. Additionally, prosthetists notes will no longer be
considered part of the patients medical record for purposes of establishing medical
necessity. Finally, any device without a serial number, part number or model number is
at severe risk of not being reimbursed for absence of a sufficiently extensive
description. The article concludes with the discussion of what actions the AOPA have
taken in this issue.
This article is very useful to me because if offers the key changes, as well as
some reasons as to why theyre negative, in the Draft LCD proposal. It mentions a few
points that were not in the webinar I cited from the Amputee Coalition, so it is not simply
repeating the same ideas. While the steps that the AOPA took are not necessarily
important to me, they are important to see just how difficult it is to make an impact.
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