Medicare

[mitchee]

Does anyone know how often Medicare will pay for a new foot? More precisely, how do you get Medicare to pay for a different foot? A friend of mine is on Medicare and he wants to get a different foot. He has surpassed the capabilities of his current prosthetic foot. His prosthetist told him that Medicare will pay for a new foot every 4 or 5 years. He has had his current foot for a couple of years. I know that some people have gotten a new foot in less than 4-5 years. How did you do it? Is it based on medical necessity? Does he need a prescription stating that he needs a different foot because he surpassed the capabilities of his current foot?

Thanks in advance for any insight.

[pegleg1az]

He will need a script for the foot and if it is a upgrade, they will have to explain why.
I just been ok'ed for a new socket and foot after 2 1/2 yrs.

With my old insurance they would not pay for the upgrade just a replacement of the same or lesser model.

[tedatrowercpo]

The standard is medical necessity but it is applied differently in different parts of the country.

Medicare has four different companies that administrate claims for prosthetic services. Each covers a different group of states. They also tend to enforce the rule to different degrees. Technically Medicare rules expect a prosthesis to last for five years. Some of the carriers take this very literally and challenge any billing that is more frequent. Other carriers do not seem to pay much attention to the rule if a reasonable period of time has passed. Wisconsin is in region B where the enforcement of this rule is not so strict. If the claim was challenged a letter from the physician supporting the medical necessity of the foot would do the trick.

[mitchee]

Thanks Pegleg1az and Ted! I appreciate the info and will pass it on. :-)

Michelle