Medical Necessity:

What Everyone Should Know

by Phyllis Bell Stong

Since most amputees rely upon some type of third-party funding (insurance, Medicare, Medicaid, VA, Vocational Rehabilitation, etc.) to pay for their prostheses, it is vitally important for amputees to understand how third-party payers determine whether or not to pay for a particular prosthesis.

One of the most common controls that third party payers employ is to insist that the prosthesis be "medically necessary," as certified by a physician. This means that the amputee or his/her prosthetist must obtain a statement from the amputee’s doctor stating that the limb is medically necessary and stating one or more reasons why it is. Sometimes the physician is required to state that certain features of the limb (special liners, hydraulic knees, energy-storing feet, etc.) are medically necessary and to give an explanation. These statements of "medical necessity" are coming under more intense scrutiny in today’s health care environment of cost control, managed care, and utilization review. It is very important that amputees, as knowledgeable consumers of health care, know how to deal with the concepts of "medical necessity," especially as they pertain to prosthetics. I am going to explore some of the reasons that a prosthesis may be "medically necessary," and thus be reimbursed by a third-party payer.

Problems with prosthetic socket fit usually constitute a "medically necessary" cause for adjustment or socket replacement. Examples of fit problems include pain, bruising, pressure sores, chafing, excessive tissue bulging over the socket, or excessive looseness. The use of diagnostic test sockets, flexible socket materials, contoured sockets, and improved suspension techniques may alleviate many socket problems and improve an amputee’s comfort and outcome.

Significant changes in weight and muscle volume are also valid reasons that prosthetic adjustment or replacement may be "medically necessary." Usually weight change of more than five pounds will affect the fit of the prosthetic socket. Muscle atrophy or muscle hypertrophy will also alter socket fit.

Physical problems with the residual limb are not the only reason that a new prosthesis may be "medically necessary." Back, neck, and shoulder pain; poor body alignment; excessive energy expenditure; and other problems with the rest of the body may justify the "medical necessity" of a new prosthesis. An ill-fitting socket, poorly-aligned prosthesis, incorrect length, or an excessively heavy prosthesis may cause problems with the whole musculoskeletal system. Prosthetic adjustments or replacement can often eliminate or ease these problems. Lighter weight, improved suspension methods, and energy-efficient components are also recommended to reduce stress on the body.

Diabetes, cardiovascular disease, and other medical conditions may create "medical necessity" for a new limb. When a physician recommends physical exercise to help with weight control or to increase general fitness, an existing prosthesis may impede progress. Other physical impairments such as a scarred residual limb, damaged knee joints, poor tissue padding on the residual limb, and weakness of the "sound" limb may present fit or functional limitations for the amputee. These may make it "medically necessary" to use ultra lightweight components, soft liners, or other special techniques to avoid use problems.

It is extremely important that amputees discuss with their prosthetist and physician their physical status so that they can jointly identify problems and develop a "medical necessity" rationale for the new limb. Amputees should ask questions and educate themselves about their medical and physical status and learn what techniques and devices might improve it or prevent deterioration. Awareness of what is medically necessary will help the prosthetist and physician provide excellent quality care and also give the insurer the information needed to process claims in a timely manner.

Amputees should keep their physician and prosthetist informed about their physical condition and any problems they are experiencing. Keep notes following discussions with your professionals and use the knowledge of your own needs to assist them as they certify your prosthetic needs as "medically necessary."

The more thoroughly you as an amputee consumer understand your own needs and desires, the more you know about what is available to you, and the more active you are in advocating for yourself, the more you will get what you  really need and want. Educate yourself, communicate with the professionals who are working with you, and advocate for your own needs!

Phyllis Bell Stong is director of Support Services at Sabolich Prosthetics in Oklahoma City, Okla., a division of NovaCare. She supervises the financial services department and works with insurance companies around the United States. She also serves as treasurer for the Amputee Coalition of America
 

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