In this last series of articles on therapeutic shoe/insert claims, there is another common scenario often faced by those providing services covered by the Medicare Therapeutic Shoe Policy. In this scenario, a patient has already received three pairs of custom inserts and now has undergone a trans metatarsal amputation. Can they be provided with a custom fabricated toe filler for the foot receiving the amputation?
The answer you have likely read elsewhere is no. The answer may be no with a BUT perhaps it is yes. It all depends.
If the patient has a trans metatarsal amputation both at the time you examine them and at the time you want to provide them with inserts, for that calendar year, then you can only provide them with inserts on the residual (intact limb) and can choose to either provide custom inserts OR a custom toe filler, L5000, but not both.
Now assuming that patient does not do well with the custom inserts, or another physician or supplier has already provided them with an insert, you can you provide them with a lower limb prosthetic toe filler, L5000. This even during that same calendar year. However, you may upon audit receive some push back from Medicare if your chart does not adequately document what changed from the time the original custom inserts were dispensed to when the prosthetic toe filler was dispensed. As noted, this will be especially troublesome if this occurs during the same calendar year that the custom inserts were dispensed.
Examples of adequate documentation illustrating that the toe filler was now required may include:
The patient’s instability has worsened since receiving the custom inserts three months ago and is primarily due to advancing diabetic neuropathy and the MSK instability due to the trans metatarsal amputation. This has resulted in multiple instances where the patient twisted their ankle and reported to our clinic for treatment of this condition. Please refence previous DOS…..
Another possibility is that patient has lost much of the influence of the intrinsic and extrinsic evertors, resulting in a fifth metatarsal base hyperkeratosis along with lateral instability. A posted lower limb custom toe filler will address the excessive inversion the patient is experiencing and offload the lateral column, thereby reducing the plantar pressure on the fifth metatarsal base.
Another consideration is for a patient who since receiving their custom inserts, has now unfortunately undergone a TMA. At this point, one can easily document that the custom milled inserts are no longer medically necessary and the patient requires a custom fabricated toe filler. The need for the toe filler will be permanent so long as the patient does not require a more proximal amputation. Your chart also needs to incorporate elements of why the toe filler is required (as above).
The bottom line here is that Medicare does not accept the fact that the patient requires use of both the inserts and toe fillers on the same limb at the same time. Documenting what has changed since they last received an insert and why the toe filler is medically necessary are equally important. Also remember that toe fillers are part of the Lower Limb Prosthetic Policy and are without all the fanfare of the Therapeutic Shoe Policy. Also, prosthetics can be replaced as often as medically necessary and are not limited by the frequency limitations of either the Therapeutic Shoe or AFO LCD.
