In a significant move to enhance the quality of life for individuals who use prosthetic knees, the Medical Directors of the Centers for Medicare and Medicaid Services (CMS) and the Durable Medical Equipment Medicare Administrative Contractor have announced a major update to the Local Coverage Determination L33787 for Lower Limb Prostheses. Beginning September 1, 2024, this new policy expands coverage for microprocessor-controlled prosthetic knees (MPKs) to include Medicare Functional Classification Level 2 (commonly known as “K-2”) beneficiaries.
This decision is backed by extensive clinical research and stakeholder advocacy, highlighting the therapeutic benefits of MPKs for people who wear lower limb prostheses. The Amputee Coalition was one of the stakeholders who advocated for this new policy through a comment letter sent in March 2024.
What This Means for People with Medicare Insurance
The updated policy is a game-changer for people seeking a new above-knee and/or hip disarticulation prosthesis or prostheses, who are classified as having a “K-2” level activity by their physician and prosthetist. Someone with a “K-2” level of activity can walk confidently outside of their home and navigate curbs, stairs, or uneven surfaces, but are not able to do so at different walking speeds. Under this new policy, people with a “K-2” activity level can now access advanced MPKs, including fluid and pneumatic knees, which are designed to improve function, prevent falls, and reduce the fear of falling.
Enhanced Stability and Safety
MPKs provide enhanced stability and safety, particularly on uneven terrain and during activities that require a high degree of balance. This is crucial for people with the “K-2” activity level who often face challenges in maintaining stability with traditional, mechanical prosthetic knee joints.
Clinical Evidence
The clinical evidence supporting the use of MPKs is robust, showing that these devices significantly reduce the risk of falls and improve overall mobility for the people wearing them, including people with the “K-2” level classification. This evidence has been a key factor in the decision to expand coverage.
Cost-Effectiveness
While MPKs are more expensive upfront, they are cost-effective in the long run due to reduced fall-related injuries and hospitalizations. This long-term cost-effectiveness is an important consideration for both the individual and the healthcare system.
Key Requirements
To qualify for this expanded coverage, documentation by the physician and the prosthetist must demonstrate the medical need of the selected prosthetic knee, showing how it will enhance the person’s functional health outcomes and daily living activities. Additionally, alternative lower-level knee options that are not MPKs must be considered and ruled out based on the individual’s specific functional and medical needs.
A Broader Trend in Medicare Coverage
This policy update is part of a broader trend by CMS to expand coverage for prosthetics, orthotics, and durable medical equipment. Recent advancements include coverage for seat elevation in power wheelchairs, bone-anchored prostheses, and powered orthoses for individuals with paralysis or stroke. These changes reflect CMS’s commitment to improving the lives of people who have Medicare insurance through innovative medical technologies.
Looking Ahead – What This Means for People with Private Health Insurance
The expansion of MPK coverage by CMS is expected to have a ripple effect, influencing how private healthcare plans and other insurance programs cover these benefits in the future. This milestone represents a significant advancement in expanding access to prosthetic technology, offering new hope for improved function and safety.