When am I eligible for my next prosthesis?
Eligibility for a new prosthesis is a common question for amputees in our community. At a recent Paraclete Amputee Support Group meeting held at Encompass Health in Rock Hill, SC a patient asked: “when am I eligible for my next prosthesis”? The answer is….it depends. It turns out that there are many variables that determine a patient’s eligibility for a new prosthesis.
One of the most important determining factors for receiving a replacement prosthesis or components is the patient’s team of advocates. This team is often made up of doctors (primary & specialists), physical therapists, prosthetist, family, and the patient. Often this team must work together to properly document a need for a new prosthesis or replacement components for an existing prosthesis. Advocates will need to work together to prove medical necessity.
Medicare is the lynchpin with regards to eligibility on most medical treatments. This means that it is likely that most insurance companies’ coverage will closely follow a Medicare-issued guideline on coverage of a replacement prosthesis. The life expectancy of components on a prosthesis is one factor that is weighed to determine eligibility. It should be noted that Medicare views each component comprising a prosthesis to have a varying life expectancy.
- Prosthetic Socket – 3-5 years
- Foot – 3-5 years and are generally warrantied for 3-5 years.
- Liners – 6 months
Again, each case is unique and eligibility is determined by the patient’s insurance provider. Conditions will vary depending on the patient’s level of activity and rate of growth (young patients) or weight loss.
K-Levels for prosthetics is a system devised to rate a patient’s functional level. This system was created by Medicare in an effort to ensure that appropriate prosthetic components are utilized. For example: If a patient is barely able to walk they might be considered a level K1. K1 patients would not have the strength to climb stairs or step up onto a curb. This patient would be rated as household ambulator according to the K-Level rating system. This patient would only be eligible for basic components under the k-level guidelines. Prosthetic components designed for a higher level of activity (K2 thru K4) would not be covered under the Medicare policy (therefore nor would it be covered by the majority of insurance companies). Who determines your functional ability level or K-Level? This is determined by your physician.
How do I move up from one K-Level to the next K-Level? Typically, patients gain strength and competence through physical therapy and practice. The key is to do the work necessary. Work with your physical therapist to design a plan that will allow you to gradually build the capacity for more activity and increase your functional ability levels.
K-Levels Range from K0 to K4. The descriptions below are from the Medicare guidelines on the subject:
Functional level 0:
The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance his/her quality of life or mobility.
Functional level 1:
The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
Functional level 2:
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. Typical of the limited community ambulator.
Functional level 3:
The patient has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
Functional level 4:
The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.
Remember that a physician must identify a patients K-Level potential to justify a need for a new prosthesis if activity level is the justification for the prosthesis. This is assuming the need for a new prosthesis is within the allowable window for a new prosthesis per the Medicare guidelines.
If there is a need for new prosthesis we would encourage to work with your team of advocates to validate the need or medical necessity. Your team consists of your physician, physical therapist, prosthetist, family, friends, and YOU! There is no greater advocate than determination so never forget that at POI…WE BELIEVE IN YOU!