Durable Medical Equipment Claims Paid by National Heritage Insurance Company, Inc., Did Not Always Meet the Requirements of the Local Coverage Determination for Lower Limb Prostheses.

摘要

65 and over, people with disabilities, and people with permanent kidney disease. CMS administers the Medicare program. Section 1862(a)(1)(A) of the Act requires that, to be paid by Medicare, a service or an item must be reasonable and necessary for the diagnosis or treatment of illness or injury or improve the functioning of a malformed body member. According to the Act, Medicare Part B provides for the coverage of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). A lower limb prosthesis is an artificial replacement for any or all parts of a leg; it provides an individual who has an amputated limb with the ability to perform functional tasks, particularly walking, that may not be possible without the device. A prosthesis joins the beneficiarys residual limb at one of several sites, such as the hip, knee, ankle, or foot. For a lower limb prosthesis to be covered by Medicare, the patient is expected to reach or maintain a defined functional level and be motivated to ambulate. Functional levels range from level 0 to level 4 and are indicated on prosthetic claims by modifiers K0 to K4. A K0 functional level modifier identifies a beneficiary who does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance his or her quality of life or mobility. In contrast, a K4 functional level modifier is for a beneficiary who has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills; this level is typical of the prosthetic demands of the child, active adult, or athlete.