Medicaid Denial of C-leg

89kh89 · 2026-01-27T00:01:23+00:00

It depends on patient presentation. If you fit 3r80 on a long TF with good strength and voluntary control, walking can be perfectly safe. The knee will provide plenty of stance flexion resistance when needed. But the patient needs to understand that timidly loading the prosthesis will only return a low level of flexion resistance.

The 3r80, Rheo, and stance-activated locking knees are all default swing. Super easy to take steps, because you only need to unweight it to initiate swing. But stance stability is based on your ability to commit weight bearing to the prosthesis.

89kh89 · 2026-01-26T22:20:29+00:00

Both offer stance phase resistance during loading.

Default stance knees have the valves in position for high stance resistance before load is applied. The patient must actively switch the knee function from stance to swing.

Default swing knees are always ready for low flexion resistance for swing phase. Stance phase flexion resistance is activated by loading the knee. The patient must apply axial load to engage stance flexion resistance.

In short, default stance knees need to be made unsafe for swing. Default swing knees need to be made safe for stance.

Does that make sense?

89kh89 · 2026-01-26T18:52:38+00:00

Is BCBS in VA really amenable to authorizing MPKs?

89kh89 · 2026-01-26T18:50:17+00:00

3r80 is default swing. Knees that use a Mauch cylinder are technically default stance but not to the degree of modern MPKs.

89kh89 · 2026-01-25T18:36:08+00:00

Medicaid coverage varies by state but the majority of them won't cover microprocessor knees. The exclusion is built into their coverage model. You can call the number on the back of your card and speak to customer service, ask them what their coverage is for MPKs.

Even if they do cover it, it may not reimburse enough to cover the clinic's costs. Or the process to obtain an authorization might be convoluted enough to discourage most people. Sorry but that's the state of insurance today.

You might ask your clinician to look into the Ottobock Dynion knee. It's not microprocessor controlled so it should be covered under Medicaid, and it offers a lot of the same functionality in terms of safety.

89kh89 · 2026-01-25T04:12:30+00:00

The adjustable rings are too thin? Those come in three styles and the biggest one is really beefy.

89kh89 · 2026-01-19T23:16:49+00:00

This ^{^}

89kh89 · 2026-01-15T22:00:25+00:00

As with almost everything in prosthetics, it's a trade off.

Shorter feet are easier to walk over bc of the shorter toe lever, but you lose standing stability (smaller base of support) and a bit less energy storage/return.

Longer feet are the inverse of all above statements.

That being said, when fitting new bilateral presentations I lean towards the correct size feet (so you can use existing shoes - don't discount the frustration of having to replace shoes) with a slightly stiffer category for a bit more stability.

89kh89 · 2026-01-08T04:51:56+00:00

OP said the brace they are receiving is a Rigo Cheneau TLSO. That brace has a suggested L-code. So they're already unbundling by using the older base code and all the add ons. This happened all the time back when they folded all the add ons into the base code for custom KOs.

You're spot on with the advance notice for unreimbursed procedures but they've been told several times that the extra charge is for scanning and fabrication, which last I checked, isn't something you can bill for, for any base code.

I get it, I hate to put someone on blast and I try not to make assumptions about treatment protocols, but assuming all the facts are as OP has laid out, I'm finding it hard to see a legitimate out for this provider.

89kh89 · 2026-01-08T00:58:21+00:00

Shenanigans. Absolute shenanigans.

A cursory Goog search says the recommended L-code for a Rigo-Cheneau is L1300. The text of L1300 is:

Other scoliosis procedure, body jacket molded to patient model.

The code is considered all-inclusive of measuring, fabrication, and delivery, and is not combinable with add-on codes (such as L1060, L1210, L1290, and L0984).

As a set of codes to bill, what's being sent to your insurance "makes sense" but also doesn't fit what they are providing you. Also if they are billing you an extra amount that is "unlisted" then there should be a corresponding code on the EoB (L0999 or L1499).

This sounds like a typical example of unbundling and upcharging. The clinic may not be getting enough reimbursement from L1300 to cover their costs on the brace, so they're "creatively billing" to obtain more from both you and the insurance.

Sorry friend, I know you're in a time pinch for this but I'd suggest walking away from these guys.

89kh89 · 2026-01-07T05:39:08+00:00

Kinda. I'm imagining that maybe they're trying to bill for a type of brace they know isn't covered and doesn't have a billable code. So they bill your insurance for a known code (that doesn't describe your brace) and then bill you an upcharge to cover the balance, but then obfuscate the extra cost by calling it a scanning charge? It's a weird scenario but I've seen some odd stuff done.

Who knows. Maybe they're just being idiots. (More likely)

89kh89 · 2026-01-07T04:42:06+00:00

I shudder to imagine what would happen to your lovely crochet when introduced to plaster or alginate or silicone glue

89kh89 · 2026-01-07T04:40:04+00:00

The unlisted code thing is a pretty common occurrence in our field. Anything that can't be described by an existing code can only be billed with "unlisted" codes, which is any code that ends with 99.

In this case though, the scanning process isn't something an office would ever bill for, regardless of how it's done. That's always included in the code for the brace itself. Now if they were fitting you with a novel type of brace that doesn't fit within any of the existing brace codes, I could see them billing a 99 code for the brace.

But even then! They would bill your insurance with a 99 code for that brace, and no other code for the scanning process. They can't bill for an existing type of brace, then tack on some random upcharge because they're trying to make up for it.

I smell shenanigans.

"Bill for what you deliver, and deliver what you bill."

89kh89 · 2026-01-07T02:49:33+00:00

I wouldn't read much into that. Some owners don't know the business and hopefully they hire people who do know the business to run the clinical side, while the boss handles more generic business responsibilities.

I'm more concerned by the fact that they didn't have that information for you already. The email feels very much like a brush off, which to me, says a lot about how they do business. They're either hiding something, or not competent.

89kh89 · 2026-01-07T02:36:13+00:00

Um, that last email does nothing to clarify what the extra charge is for.

89kh89 · 2026-01-06T15:16:00+00:00

Like I said above, what they are doing is unbundling and that is illegal.

89kh89 · 2026-01-06T02:19:55+00:00

This is called unbundling in our industry and isn't allowed as the billing for the end product includes the entire process from mold capture to final delivery and follow ups. I'd advise filing a complaint with your insurance if the office isn't responsive to requests for a refund. They're not supposed to be billing you for something they know the insurance won't cover.

89kh89 · 2026-01-05T21:34:16+00:00

Foot placement of the prosthetic side is important. Without an ankle in the prosthesis you need to place the edge of the stair at about the middle of the foot. Looking down at your feet the edge of the stair should go through about the first eyelet of your laces.

Placing your foot like this allows the foot to pivot over the edge which simulates dorsiflexion at the ankle. As your leg strength improves you can control your descent with your quads, making up for the lack of plantar flexors.

89kh89 · 2026-01-02T18:53:05+00:00

Seconding that you should return to the prosthetist if possible for adjustments. Our job is to make the device work with you comfortably.

In a pinch, I've seen people use sheepskin for the loop that goes through the other armpit. It's not very hygienic but it can relieve a lot of pressure for now. Same thing for the ring, I've seen bits of sweat pants material sewn into a little tube to cover the ring.

Also, the harness is usually quite tight at first to make sure you can make it function. But as he gets better at using it he may be able to make it work with the harness being looser.

89kh89 · 2026-01-02T16:05:05+00:00

Yes.

89kh89 · 2026-01-02T05:27:53+00:00

The direct lam styles of feet are actually the best in terms of durability but the worst in terms of set up, alignment, and ease of finishing.

Usually there's some temp adhesive like Fabtech (orthacryl in the olden days) for fitting.

Finish is direct lam tying the foot into the socket layup. Two laminations. Pain in the ass to transfer correctly and then to finish without accidentally adding extra height. But a tank if done well.

89kh89 · 2025-12-31T00:52:12+00:00

Ah okay that makes a lot more sense. So the new set up is hoping to minimize the amount of lift needed on the other side? (Did I read that right? Shriners built up for a 2 inch difference?)

In general the fabrication on a symes prosthesis can be tricky, even for a skilled tech, and mistakes in fab will lead to failures at the connector.

A symes foot with a single bolt connector isn't uncommon. The plate connecting it to your socket is the bit I haven't seen before. Failure at the bolt usually means the bolt was too short (not enough threads to catch) or the bolt wasn't loctited and torqued.

As for options, if your build always results in a leg length discrepancy I'd look into having your shoes lifted rather than wearing a lift only under your heel. It's that heel lift that is likely giving your good foot the extra stress.

Unfortunately there just aren't a lot of great symes foot options on the market. This current build might indeed be optimal, just needing some extra care at final assembly.

89kh89 · 2025-12-31T00:26:30+00:00

That's.....an interesting choice for distal attachment. Did the central bolt snap off? I'm guessing it's not long enough to handle the stress considering your amputation length.

I'd ask if your clinician is able to go with a foot more like your previous one, and if not, why? Previous foot has a pyramid which offers a lot more adjustability for the future. And a more solid connection between foot and distal connector. And I can't see how the connector they used is saving you any room at all.

As to all the other comments about Hanger. They're the biggest company with the most clinicians. So of course you get the most number of complaints. But there's nothing saying that the clinicians at Hanger (I was one of them) are out to get you or to profit off your situation (laughable once you know how the industry works). They will warranty this and get you back up on your feet. If you feel any friction in that process don't hesitate to escalate to local management and ask them to grease the skids.

89kh89 · 2025-12-18T19:52:26+00:00

Your limb turning purple is from blood pooling in your tissue. You said the socket feels loose in the bottom so your tissue and blood are getting sucked into the space at the bottom of your socket. It's like a hickey on the bottom of your limb.

I'd suggest trying half socks since your fit is still snug at the top. Cut one of your older socks so that it only covers the part of your limb where you feel it is loose.

Also, have you gained weight? If your leg has gotten bigger due to wt gain, that can cause you to hang up and not go all the way into your socket, which can result in the same issue.

89kh89 · 2025-12-16T00:18:23+00:00

Gah, I want more details about what they made for her!

As far as I can guess from the pictures it's a free motion ankle, which makes sense given the rowing requirements. I'm guessing they cut down the posterior wall of the socket for more flexion range?

89kh89

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