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  • Writer's pictureWinkleyOP

Insurance Documentation For New Prosthesis

Updated: Jun 24, 2021

In order to meet Medicare requirements for a new prosthesis, (and typically every other type of insurance) there will need to be documentation that is quite specific in the doctor visit notes. This visit must occur before the process of a new prosthesis can begin.

First off, one of the best ways to obtain the necessary information a little bit faster, is to see a Physical Medicine & Rehabilitative (PMR) Doctor for your prosthetic care. We always understand if someone is not interested in setting up an additional appointment with someone new when it comes time to get the documentation, this isn't a necessity, it just helps the process.

A PMR doctor is more specialized regarding the application of prosthetic devices, as well as looking at what other help may be needed along the way, (Physical Therapy, Occupational Therapy, prosthesis-specific issues with skin or pain, the effects on comorbidities) so may be worth the extra appointment in the long run as a new amputee. We can always work with your existing primary doctor to obtain the notes needed as well.

Referring Your Patient To Prosthetist
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A full evaluation should be done to assess a patient's Functional Level (K Level) as well as the discussion of whether the patient is motivated to use a prosthesis, and what type of activities prior to amputation were participated in and moving forward what goals or activities would the patient like to return to. The following list is a thorough baseline:

  • "History of your present condition(s) and past medical history relevant to functional deficits

  • Symptoms limiting ambulation or dexterity

  • Diagnoses causing these symptoms

  • Other co-morbidities relating to ambulatory problems or impacting use of a new prosthesis

  • What ambulatory assistance (cane, walker, wheelchair, caregiver) currently in use (either in addition to the prosthesis or before amputation)

  • Description of daily living activities and how they are impacted by deficit(s)

  • Physical examination relevant to functional deficits

  • Weight and height, including any recent weight loss/gain

  • Cardiopulmonary examination

  • Musculoskeletal examination – Arm and leg strength and range of motion

  • Neurological examination – Gait – Balance and coordination."

All of this information goes into an official recommendation for a prosthesis and selection of a functional level:

  • "Level Zero: The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. This level does not warrant a prescription for a prosthesis.

  • Level One: The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. This is typical of a household ambulator or a person who only walks about in their own home.

  • Level Two: The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces. This is typical of the limited community ambulator.

  • Level Three: The patient has the ability or potential for ambulation with variable cadence. A person at level 3 is typically a community ambulator who also has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple locomotion.

  • Level Four: The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. This is typical of the prosthetic demands of the child, active adult or athlete. "

This functional level must be written out in the documentation, especially if an entire prosthesis is to be prescribed (knee + foot componentry since this K Level dictates what will be covered).

All of this information regarding the rehab potential of the amputee, their motivation to ambulate with a prosthesis, a documented K-level, recommendation for a prosthesis and sometimes detail regarding a specific type of knee or foot (microprocessor controlled ankle or knee) must then be directly documented in the patient's medical record for it to meet all Medicare requirements for coverage. This information will all need to corroborate with the prosthetists' evaluation and recommendations as well, but the doctor's note will be the primary documentation for the medical necessity of a prosthesis.

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