Medical Necessity in Prosthetics and Orthotics: Moving from Device Deliverers to Healthcare Providers

Expert panel short presentations describing different aspects of Medical Necessity in P&O with a case-study based breakdown at the end and audience Q&A. Medical Necessity reasoning for P&O devices and features is a public funding source (Medicare/Medicaid) requirement and often requested by commercial payers as well. However, many practitioners struggle with how to write medical necessity vs. functional needs or patient desires as reasoning for components or features. The definition of medical necessity is vague enough to require support in interpretation and application. Until passage of the 2018 law that our records are part of the medical record, we were not often required to make robust medical necessity arguments in our clinical notes as we are today. Therefore, more education and support in this area is needed. Likewise, the shift from fee for service to value-based care for custom devices especially, requires a shift from device delivery to provision of healthcare and being part of the healthcare team in all aspects not least of which is communication (records).

Learning Objective: 

The audience will recognize the difference between medical necessity and functional needs or desires

Participants will gain a basic understanding of what type of medical record information can inform medical necessity for an expected health outcome after provision of the prosthesis or orthosis

Participants will learn a method for processing medical information so it can be applied to medical necessity-based reasoning for prosthetic and orthotic care