CMS Reverses Its Position on Replacement of a Prosthesis Without a New Prescription


On April 24, 2013, CMS announced that Medlearn Matters Article SE1213 had been revised to remove a statement that indicated that a prosthesis could be replaced without a new order from a physician as long as there was no upgrade from the previously ordered prosthesis.  This statement was originally added to Medlearn Matters Article SE1213 in a revision dated June 7, 2012.

AOPA is deeply concerned about the removal of this statement as it represents another example of the failure of CMS to provide reliable coverage guidance to providers of orthotic and prosthetic devices.  When the statement was initially added to the article in June of 2012, AOPA was concerned that it seemed to create conflict with Chapter 15, section 110.2 of the Medicare Benefit Policy Manual which addresses replacement of DMEPOS and clearly states that a new order is necessary to reaffirm the medical necessity of the item.  While the removal of the statement from the Medlearn Matters article seems to resolve this conflict, the fact remains that for almost a year, there was a CMS publication in circulation that provided guidance that was in direct conflict with its own Benefit Policy Manual.  The revision of the article to remove this statement effectively means that in CMS’ eyes, the statement never existed.

AOPA was wary of this statement from its initial publication and has continued to recommend that a new order should be obtained when replacing any O&P device regardless of the reason for replacement.  With the removal of the statement from the Medlearn Matters Article regarding replacement of a prosthesis without obtaining a new order, AOPA must reiterate its recommendation to obtain a new order when replacing any O&P device.

AOPA will express its concern to CMS regarding the confusion that publication and subsequent removal of this statement from the Medlearn Matters Article has caused.

Link to April 2013 (current) version can be found here.

Link to June 2012 (previous) version can be found here.

Questions regarding this issue may be directed to Joe McTernan or Devon Bernard.