PPageage 4 Navigating the O&P Insurance Maze atients receiving a prosthetic or orthotic device for the first Prosthetic and orthotic coverage definitions in many policies may time may experience confusion and frustration at the often be vague and thus open to interpretation as to whether requested Plengthy and mysterious process of obtaining insur- items or services are “medically necessary.” Coverage is also gener- ance approval for the prescription their doctor has writ- ally limited to the item or service deemed the “least ten for them. The costly most functional alternative,” also often unde- In what some remember as the “good old days” of fined. As a result, we are many times required to justify private indemnity insurance, delivery of orthoses and Financial each of the components and services we intend to pro- prosthetic limbs was seldom delayed by third-party vide with numerous back-and-forth communications intervention. The insurance company paid for the Side between our staff and the case manager...and the clock device the doctor prescribed minus any deductibles keeps ticking. Prosthetics • Orthopedic Bracing • Seating & Mobility No. 7 specified in the policy. That was then. Today, we operate under a Eventually, we are usually able to provide a satisfactory prosthetic whole new “alphabet soup” of insurance plans with different and or orthotic solution for the patient’s needs. It’s an imperfect system, detailed rules and requirements. but we strive to help all concerned navigate the O&P insurance maze. The net result is that doctors and prosthetist-orthotists no longer If you have a specific question about Medicare or private insur- A ‘Stimulating’ Orthotics Advance fully determine what prosthetic or orthotic device a patient will ance coverage, contact our office. receive under insurance coverage...the ultimate decision-maker in new modality has taken up residence in the orthotics disci- Electrical stimulation for standing and many cases has become the insurance carrier. Particularly in situa- New AAOS Orthotics Atlas Arrives pline, broadening rehabilitation horizons for many patients ambulation may be used in a hybrid system in tions involving newer high-tech componentry, the prescription is The fourth edition of the AAOS Atlas of Orthoses and Awith neuromuscular dysfunction and/or chronic pain. This conjunction with traditional mechanical sup- more of a recommendation to be submitted up the line for approval Assistive Devices is now available. Working in conjunction with technology amplifies, and in some cases replaces, conventional port, such as an AFO, walker, or elbow canes. (unless the payment is coming from private funds). Obtaining that the American Association of Orthopaedic Surgeons (AAOS), orthotic management with neuromuscular electrical stimulation However, in new devices developed for man- approval is not always easy or expeditious. authors John Hsu, M.D.; John Michael, CPO; and John Fisk, (NMES) to offer restored function, pain relief and other benefits to aging basic foot drop the stimulation unit may When we receive a referral for orthotic or prosthetic services, we M.D. have significantly revised the Atlas con- patients with paralysis or other deficit secondary to stroke, head or be used without auxiliary support. initially verify the patient’s coverage, normally a quick and simple tent and added a helpful two-color format. spinal cord injury, cerebral palsy, multiple sclerosis, or other condi- Contraindications for using NMES include process. Then, after an initial patient evaluation based on the doc- The 672-page edition contains new chap- tions producing upper motor neuron pathway disruption. a history of cardiac or respiratory problems, tor’s prescription, we compile an authorization request to the insurer ters on cranial orthoses and orthoses for per- In many central nervous system disorders, although seizure disorders, long bone for services we intend to provide, using a series of “L-codes” estab- sons with post-polio syndromes. Each chapter the brain or spinal cord is damaged, the peripheral stress fractures, osteoporosis or lished by the Centers for Medicare & Medicaid Services (CMS) and includes sidebars with personal perspectives nerves connecting the cord to the muscles remain Orthotics joint disease; irreversible contrac- WalkAide® FES used by all U.S. payers and providers. Generally each insurer will and tips from well-known physiatrists. viable and thus responsive to electrical stimulation. tures; Guillain-Barré Syndrome; system for addressing follow CMS coverage parameters, amplified by its own policy limi- NMES and its cousins FES (functional electrical Today pregnancy; skin disease or a frac- Existing, revised chapters cover orthotic foot drop tations and exclusions. stimulation) and TENS transcutaneous electrical ture/dislocation near the stimulation prescription, strength and materials, normal and pathologic gait, Courtesy Innovative While we can usually fabricate and fit, repair or enhance a brace and biomechanics of the spine, upper limb, hand, and lower limb. nerve stimulation) are not new. However, recent improvements in site; morbid obesity; recent surgery; and use of Neurotronics Inc. or replacement limb in a timely fashion, we normally cannot begin The chapters on spinal and upper- and lower-limb orthoses miniaturizing and packaging componentry now allow stimulation certain types of pacemakers or implants. the process until we can be certain the services will be reimbursed include new evidence-based recommendations for prescription. devices to be worn effectively and comfortably on a patient’s ana- Articles on pages 2 and 3 discuss three products producing by the insurer. The review process varies by insurance company and The revised Atlas was recently priced at $159.20 at tomy, much like a mechanical orthosis. excellent results in the management of foot drop and a unique sometimes results in a denial (which we may appeal) or a request Amazon.com. These components, variously termed neuroprosthetic or myo- approach to securely surface electrodes on almost any part of the for additional information...and time passes. orthotic devices, are being successfully applied to accomplish many body. We welcome you inquiries and referrals. traditional orthotic objectives, notably to... • replicate normal muscle function • enable standing and ambulation High-Tech O&P Offering a Full Line of Patient Aids and Safety Items • alleviate chronic pain Orthopedic Appliance Company utilizes many of today’s latest orthotic and prosthetic technologies, from our in-house When it comes to walking aids, bath safety • reduce spasticity • provide therapeutic exercise CAD/CAM system and multi-axis computerized carver to the and personal care products, we at Orthopedic • improve circulation and organ latest in microprocessor-controlled knee components, to enhance lifestyle outcomes for our patients. function Appliance Company are committed to meet- Several OAC patients are now using microprocessor knees such • increase joint range of motion as the C-Leg®, ranging from new amputees to patients who have ing the needs of your patients. Our carrying • re-educate voluntary muscles and been wearing older-style knee units for more 20 years. We are • reverse muscular atrophy. staff will fit and teach proper techniques for finding that these patients are experiencing significant increases in NMES directs small electrical im- using each device. their activities as their fatigue levels have decreased, allowing them pulses to excite the nerves that supply to be more active with day-to-day tasks for longer periods. The following are some but not all of the paralyzed muscles. Electrodes may be Whatever the situation, our staff has more experience than any Wearable therapy applied on the skin surface, inserted electrode garment other facility in Western North Carolina. Our expert prosthetists items we have in stock: deep into the muscle with a needle Courtesy Bioflex Electromedicine Inc. all received training at Northwestern University in Chicago and • Folding walkers • Rolling walkers (percutaneous) or surgically implanted. are board-certified by the American Board for Certification in • Crutches • Canes Today’s orthotic electrical stimulation strategies generally seek to Orthotics and Prosthetics. maximize the effectiveness of surface applications, which are gener- We welcome your inquiries and referrals. • Shower chairs • Transfer benches ally easier on the patient and thus advantageous in the long run.

Page 2 Page 3 Foot Drop Devices Enhance FES Popularity ‘Wearable Therapy’ — Next Step In Electrical Stimulation Orthoses lthough functional electrical system consists of three distinct elements “connected” by wireless stimulation has been employed communication: ost of the buzz surrounding the incorporation of electrical therapy. The late actor in the care of neurologically 1. A leg cuff containing the stimulator component attaches to the stimulation technology into orthotic rehabilitation strategies Christopher Reeve, who A suffered a complete impaired patients for many years, the affected leg just below the knee. With the cuff properly in place, elec- Mhas centered around the portable technology has proceeded in relative trodes stimulate the peroneal nerve at the appropriate instant in the gait FES systems for foot drop described on spinal cord injury with obscurity in the orthotics-prosthetics cycle to contract the dorsiflexors and thereby lift the forefoot. page 2. However, the future of this mo- What’s resulting quadriplegia in arena until the fairly recent introduction 2. A gait sensor attached to the wearer’s shoe continuously tells the dality extends far beyond that single a fall during an eques- of portable FES systems for patients system where the leg is in the gait cycle and enables it to adjust for application. New trian competition, was Wearable therapy electrode garment Graphics courtesy Bioflex Electromedicine Inc. hampered by foot drop. uneven terrain, ramps and stairs. Electrical stimulation may be applied an early user and active This condition is a frequent symptom 3. A hand-held remote control enables the wearer to adjust the level to any muscle group in the body to counter the effects of paralysis proponent of this system. Effectively bypassing the break in the of central nervous system dysfunction, of stimulation and turn the unit on and off. resulting from spinal cord injury, stroke or other neurological impair- actor’s neurological system, the stimulation applied through Reeve’s can result from complete or partial Bioness reports the L300 is finding particular applicability among ment. Stimulation has also proven Bioflex garments kept his muscles functioning and his body healthy paralysis or general weakness of the M.S. patients. valuable in the management for several years through improved circulation, ongoing cardiopul- dorsiflexor muscles, and may be com- of localized or widespread monary exercise, increased joint range of motion, FreeStep™ pounded by plantarflexor muscle group chronic pain. diminished spasticity, and protection against undue The Bioflex Electromedicine FreeStep is described spasticity. Essential to the effective- skin pressure and attendant skin breakdown. by its creator as a NeuroProsthesis™ (meaning a Patients with foot drop are seriously Courtesy Bioness Inc. ness of this form of treatment Pain management: Neuromuscular stimulation replacement for the impaired portion of the central challenged when trying to walk. Unable to lift their forefoot normally is ensuring that the target muscle with wearable therapy is also being effectively nervous system). This system may be donned with a during swing phase, they typically either drag their forefoot and toes— or muscle group is properly stim- applied for reduction of chronic pain from different leg cuff to stimulate the peroneal nerve, or with the which can and often does precipitate a fall—or overcompensate with ulated, which requires accurate sources. Stimulation alleviates pain in various ways, company’s trademark spandex BioSleeve garment to an exaggerated high-stepping pattern known as steppage gait. Often, positioning of electrodes over including reducing tightness in muscles subject to function directly over the dorsiflexor muscle group. the difficulties of ambulating with foot drop overcome the individual’s the affected area. While this out- spasm, improving circulation, and blocking pain The FreeStep also incorporates a heel switch, motivation to walk at all. come usually can be assured in signals from reaching the brain. Experience has which triggers stimulation at heel-off at the initiation Within the past few years, several lightweight, compact FES units a clinical setting, it is often shown this approach is in many cases of swing phase and deactivates it at heel-strike and providing stimulation of the peroneal nerve have been introduced to BioVest advantageous for patients and effective for keeping pain at bay, even BioSleeve FreeStep through stance phase. The stimulation dorsiflexes the widespread market interest and acceptance and various medical prod- their caregivers to be able to with an increase in physical activity. Courtesy Bioflex foot in a physiological manner and does not restrict uct innovation awards. By enabling appropriate individuals to walk apply stimulation therapy at home, where correct electrode placement Benefits: Though still relatively new, the wearable Electromedicine ankle motion. faster, longer and more confidently with reduced fatigue, these prod- is both considerably less likely and generally more difficult. More- therapy method of electrical stimulation offers signifi- Beyond re-energizing impaired dorsiflexors, the FreeStep has been ucts are proving effective in helping people regain mobility and inde- over, the application of large numbers of electrodes sometimes cant advantages to patients and caregivers: cited as beneficial in chronic use for decreasing muscle atrophy and pendence, thereby improving quality of life and productivity. required for aggressive stimulation management can be quite • Electrodes align correctly as the suit is donned improving local blood circulation. As a result, many patients afflicted with foot drop are able to re- time-consuming...in any setting. and remain in place with activity. From a relatively place their ankle foot orthosis or other type of mechanical brace with WalkAide® Wearable therapy, a concept developed by Bioflex Electro- basic one-site system to a multiple-site arrangement a small unobtrusive unit that can be worn out of sight under clothing. Probably the best-known of the new FES orthoses for foot drop is medicine Inc., tackles those problems with a entailing as many as 46 electrodes for a quadriple- This article will discuss the three leading foot drop FES orthotic the Innovative Neurotronics WalkAide® system. Unlike the aforemen- line of custom “electrode garments” gic patient, Bioflex garments can be donned with systems in alphabetical order. tioned products, the WalkAide does not use a heel sensor after initial designed for easy donning and relative ease. programming by a qualified practitioner, but relies on a self-contained ensuring electrodes are posi- • Wearable therapy systems can be worn 6-8 Bioness L300 tilt sensor in the stimulator unit to initiate and terminate stimulation tioned accurately with each hours a day to strengthen and refunctionalize The Bioness L300 is the second during the gait cycle. The WalkAide is held in place just below the application. The garments muscles, combat spasticity and counter con- product—the N200 Hand Rehabilitation fibula head by a leg cuff. are made of spandex and feature tractures. For pain applications, the system System is the first—launched by Bioness After more than 10 years in develop- built-in lead wires that do not may be used up to 24 hours a day, including Inc., a company formed in 2004 to help ment, the WalkAide has been shown to restrict patients’ movement, walking during sleep. Bioness L300 individuals with neurological impairment give patients a smoother, more natural or sleeping. The wearable therapy system can • Electrodes and wiring do not need to be removed to Courtesy Bioness Inc. regain their independence. The Bioness and safer stepping motion. Successful work every major muscle group in the body wash the garment. users are able to walk faster and for and has been proven effective in functional, • The system may be worn and concealed under Note to Our Readers longer distances with less fatigue. neuromuscular exercise, and pain manage- clothing. The WalkAide is designed to be worn BioBelt ment applications. Wearable therapy is a promising Mention of specific products in our newsletter neither consti- Functional enhancement: For patients throughout the day, but is to be removed WalkAide new approach to delivering electrical tutes endorsement nor implies that we will recommend selection of whose neurological deficit will allow them to walk, wearable therapy before retiring. Like the L300 and Free- Courtesy Innovative Neurotronics Inc. stimulation therapy to a range of those particular products for use with any particular patient or Step, it should not be worn when shower- can help provide the muscle strengthening, improved circulation neurologically impaired patients Biocollar application. We offer this information to enhance professional and ing, bathing, swimming, or otherwise immersed in water. Driving while and, where required, spasticity control and/or contracture reduction and other individuals battling individual understanding of the orthotic and prosthetic disciplines wearing the WalkAide is strongly discouraged. necessary for safe and sustained standing and ambulation. Similarly, BioBelt chronic pain. Insurance cover- and the experience and capabilities of our practice. All of these systems are sophisticated medical products requiring a the system can help paralyzed patients regain use of their upper age varies with the provider and specifics of Bioflex Electromedicine Inc. • Bioness Inc. physician’s prescription, thorough patient medical evaluation and pro- extremities. the patient’s condition. Innovative Neurotronics Inc. gramming by a qualified practitioner. Coverage for these still-new Neuromuscular exercise: Even patients whose deficit will not Additional information on wearable therapy can be found at products varies by insurer. allow substantial functional improvement can benefit from wearable wearabletherapy.com. 2-08 S PPageage 4 Navigating the O&P Insurance Maze atients receiving a prosthetic or orthotic device for the first Prosthetic and orthotic coverage definitions in many policies may time may experience confusion and frustration at the often be vague and thus open to interpretation as to whether requested Plengthy and mysterious process of obtaining insur- items or services are “medically necessary.” Coverage is also gener- ance approval for the prescription their doctor has writ- ally limited to the item or service deemed the “least ten for them. The costly most functional alternative,” also often unde- In what some remember as the “good old days” of fined. As a result, we are many times required to justify private indemnity insurance, delivery of orthoses and Financial each of the components and services we intend to pro- prosthetic limbs was seldom delayed by third-party vide with numerous back-and-forth communications intervention. The insurance company paid for the Side between our staff and the case manager...and the clock device the doctor prescribed minus any deductibles keeps ticking. Prosthetics • Orthopedic Bracing • Seating & Mobility No. 7 specified in the policy. That was then. Today, we operate under a Eventually, we are usually able to provide a satisfactory prosthetic whole new “alphabet soup” of insurance plans with different and or orthotic solution for the patient’s needs. It’s an imperfect system, detailed rules and requirements. but we strive to help all concerned navigate the O&P insurance maze. The net result is that doctors and prosthetist-orthotists no longer If you have a specific question about Medicare or private insur- A ‘Stimulating’ Orthotics Advance fully determine what prosthetic or orthotic device a patient will ance coverage, contact our office. receive under insurance coverage...the ultimate decision-maker in new modality has taken up residence in the orthotics disci- Electrical stimulation for standing and many cases has become the insurance carrier. Particularly in situa- New AAOS Orthotics Atlas Arrives pline, broadening rehabilitation horizons for many patients ambulation may be used in a hybrid system in tions involving newer high-tech componentry, the prescription is The fourth edition of the AAOS Atlas of Orthoses and Awith neuromuscular dysfunction and/or chronic pain. This conjunction with traditional mechanical sup- more of a recommendation to be submitted up the line for approval Assistive Devices is now available. Working in conjunction with technology amplifies, and in some cases replaces, conventional port, such as an AFO, walker, or elbow canes. (unless the payment is coming from private funds). Obtaining that the American Association of Orthopaedic Surgeons (AAOS), orthotic management with neuromuscular electrical stimulation However, in new devices developed for man- approval is not always easy or expeditious. authors John Hsu, M.D.; John Michael, CPO; and John Fisk, (NMES) to offer restored function, pain relief and other benefits to aging basic foot drop the stimulation unit may When we receive a referral for orthotic or prosthetic services, we M.D. have significantly revised the Atlas con- patients with paralysis or other deficit secondary to stroke, head or be used without auxiliary support. initially verify the patient’s coverage, normally a quick and simple tent and added a helpful two-color format. spinal cord injury, cerebral palsy, multiple sclerosis, or other condi- Contraindications for using NMES include process. Then, after an initial patient evaluation based on the doc- The 672-page edition contains new chap- tions producing upper motor neuron pathway disruption. a history of cardiac or respiratory problems, tor’s prescription, we compile an authorization request to the insurer ters on cranial orthoses and orthoses for per- In many central nervous system disorders, although seizure disorders, long bone for services we intend to provide, using a series of “L-codes” estab- sons with post-polio syndromes. Each chapter the brain or spinal cord is damaged, the peripheral stress fractures, osteoporosis or lished by the Centers for Medicare & Medicaid Services (CMS) and includes sidebars with personal perspectives nerves connecting the cord to the muscles remain Orthotics joint disease; irreversible contrac- WalkAide® FES used by all U.S. payers and providers. Generally each insurer will and tips from well-known physiatrists. viable and thus responsive to electrical stimulation. tures; Guillain-Barré Syndrome; system for addressing follow CMS coverage parameters, amplified by its own policy limi- NMES and its cousins FES (functional electrical Today pregnancy; skin disease or a frac- Existing, revised chapters cover orthotic foot drop tations and exclusions. stimulation) and TENS transcutaneous electrical ture/dislocation near the stimulation prescription, strength and materials, normal and pathologic gait, Courtesy Innovative While we can usually fabricate and fit, repair or enhance a brace and biomechanics of the spine, upper limb, hand, and lower limb. nerve stimulation) are not new. However, recent improvements in site; morbid obesity; recent surgery; and use of Neurotronics Inc. or replacement limb in a timely fashion, we normally cannot begin The chapters on spinal and upper- and lower-limb orthoses miniaturizing and packaging componentry now allow stimulation certain types of pacemakers or implants. the process until we can be certain the services will be reimbursed include new evidence-based recommendations for prescription. devices to be worn effectively and comfortably on a patient’s ana- Articles on pages 2 and 3 discuss three products producing by the insurer. The review process varies by insurance company and The revised Atlas was recently priced at $159.20 at tomy, much like a mechanical orthosis. excellent results in the management of foot drop and a unique sometimes results in a denial (which we may appeal) or a request Amazon.com. These components, variously termed neuroprosthetic or myo- approach to securely surface electrodes on almost any part of the for additional information...and time passes. orthotic devices, are being successfully applied to accomplish many body. We welcome you inquiries and referrals. traditional orthotic objectives, notably to... • replicate normal muscle function • enable standing and ambulation High-Tech O&P Offering a Full Line of Patient Aids and Safety Items • alleviate chronic pain Orthopedic Appliance Company utilizes many of today’s latest orthotic and prosthetic technologies, from our in-house When it comes to walking aids, bath safety • reduce spasticity • provide therapeutic exercise CAD/CAM system and multi-axis computerized carver to the and personal care products, we at Orthopedic • improve circulation and organ latest in microprocessor-controlled knee components, to enhance lifestyle outcomes for our patients. function Appliance Company are committed to meet- Several OAC patients are now using microprocessor knees such • increase joint range of motion as the C-Leg®, ranging from new amputees to patients who have ing the needs of your patients. Our carrying • re-educate voluntary muscles and been wearing older-style knee units for more 20 years. We are • reverse muscular atrophy. staff will fit and teach proper techniques for finding that these patients are experiencing significant increases in NMES directs small electrical im- using each device. their activities as their fatigue levels have decreased, allowing them pulses to excite the nerves that supply to be more active with day-to-day tasks for longer periods. The following are some but not all of the paralyzed muscles. Electrodes may be Whatever the situation, our staff has more experience than any Wearable therapy applied on the skin surface, inserted electrode garment other facility in Western North Carolina. Our expert prosthetists items we have in stock: deep into the muscle with a needle Courtesy Bioflex Electromedicine Inc. all received training at Northwestern University in Chicago and • Folding walkers • Rolling walkers (percutaneous) or surgically implanted. are board-certified by the American Board for Certification in • Crutches • Canes Today’s orthotic electrical stimulation strategies generally seek to Orthotics and Prosthetics. maximize the effectiveness of surface applications, which are gener- We welcome your inquiries and referrals. • Shower chairs • Transfer benches ally easier on the patient and thus advantageous in the long run.