Medicare has mandated new height requirements for ankle-foot orthoses (AFO) in a policy statement issued in July 2012. All practitioners must now dispense ankle-foot orthoses that reach a height within 4 cm of the head of the fibula. As a clinician who uses AFO devices regularly, I find this mandate challenging. As an owner of an AFO company, I view this challenge as a bewildering nightmare.
Medicare instituted these new requirements without any opportunity for public comment or discussion. The language states:
“Ankle-foot orthoses described by codes L1900, L1910-L1990 extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. The terminal height of an AFO shall be located between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4 cm distal to the apex of the head of the fibula). These features distinguish them from foot orthotics ...”1
I have discussed this issue with American Podiatric Medical Association (APMA) members who are in close communication with carrier medical directors of Durable Medical Equipment Medicare Administrative Contractors (DME MACs). It is my understanding that the decision to require full-leg AFO devices was not based upon any valid science. Negotiations among Medicare, the APMA and other professional organizations are ongoing, and we hope for some kind of reversal.
Notwithstanding, we must now dispense full-leg AFO devices. These are going to be more bulky and pose more challenges for patient adherence than traditional mid-leg AFOs. Throughout the past 15 years, peer-reviewed medical publications have published several high quality studies that document significant positive treatment effects of using mid-leg AFO devices for posterior tibial tendon dysfunction.2-7 Many patients in these studies were able to discard their AFO devices after one year of use and remain pain-free for as long as seven years after treatment.
I now have to design new types of AFO braces that conform to the new Medicare height requirements. All of the new braces would not only be bulkier but would also potentially be more controlling of the foot, ankle and leg. This could be a “win-win” for both the practitioner and the patient. If we could design a brace that would start out with maximum control of the lower leg and foot and clinicians could also modify it to increase the mobility of the patient as healing occurs, then the patient could end up with a low profile device or no device at all.
Further research into this treatment strategy reveals that practitioners have used a “step down” for many years in the treatment of spinal injuries or surgeries. Spinal braces have been designed for modification as the patient heals or requires surgery, and one can allow more mobility.8-9
Given that most medical indications for AFO therapy in the clinical setting are conditions that are expected to improve over time, the introduction of a “step down” approach now seems perfectly timed with the new Medicare requirements. It may be acceptable to start with a bulkier, more controlling device as long as one can modify it as patient recovery proceeds. I have written a white paper on this subject that outlines how to implement my new braces according to this new protocol.10
1. Available at http://tinyurl.com/beg8v7k  .
2. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Non-operative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996; 17(12):736–41.
3. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006; 27(1):2–8.
4. Augustin JF, Lin SS, Berberian WS, Johnson JE. Non-operative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003; 8(3):491–502.
5. Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year followup. Foot Ankle International. 2008; 29(8):781-6.
6. Krause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2008; 29(11):1095-1100.
7. Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Non-operative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011; 50(3):311-314.
8. Available at http://www.ossur.com/?PageID=14238  .
9. Available at http://www.ottobockus.com/cps/rde/xchg/ob_us_en/hs.xsl/47276.html  .
10. Available at http://richiebrace.com/pdf/UltraWhitePagev2.pdf  .