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OA knee bracing reimbursement: Challenges and opportunities

Osteoarthritis bracing options are getting better, but reimbursement doesn't always support patient choice.

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Knee bracing is an option for conservative treatment of osteoarthritis, and there is a wide range of off-loading braces designed to achieve pain relief and other health benefits. Several clinical and financial factors influence the prescribing, product selection and payer reimbursement of OA braces. Townsend Design CEO Rick Riley provides his perspective on these factors and current trends related to the use of single and dual hinge OA braces.

How has the market for OA knee bracing evolved over the past 20 years?

The health consequences of decreased physical activity due to OA-related knee pain have increased awareness of the benefits of OA knee braces as conservative treatment prior to surgery. OA bracing technology is designed to shift loading forces away from the damaged side of the knee. The designers of these offloading-type braces have become more focused on patient compliance. Manufacturers have created braces that are less structurally substantial than the initial OA braces designed two decades ago using lightweight, soft conformable materials.

Are there any challenges related to reimbursements for OA bracing technology?  

Townsend Design CEO Rick Riley

There are established reimbursement codes for OA braces. One interesting challenge for our company is the odd reality that reimbursement for single upright braces is higher than the reimbursement for double upright OA braces. Published studies indicate patients with unicompartmental OA benefit from either wearing single hinge or dual hinge offloading braces. We urged the Centers for Medicare & Medicaid Services (CMS) to set reimbursement at the same level for OA braces, regardless of whether they have one or two hinges. We also felt reimbursement for OA knee braces should be higher than for ligament knee braces because OA braces are fabricated for an older, more complex patient population.

We asked CMS to change the code descriptor for L-1843 and L-1844, which referenced only single hinge braces, to add the words or dual hinge braces with varus/valgus adjustment — a two-word change. Instead, CMS added two different words to the code descriptor for L-1843 and L-1844. They also added the same two words to the description for the double hinge L1845 and L-1846 codes. They changed the descriptor from with varus/valgus adjustment to with or without varus/valgus adjustment. This decision financially incentivizes use of single upright braces for OA patients and for patients who have ligament instabilities. I don’t know what studies or clinical evidence CMS relied on in determining single-hinge braces are safe and effective for treating instabilities. As a result, Townsend now manufacturers single and dual hinge OA braces.

How do government documentation requirements affect utilization and reimbursement of OA knee braces?

As is the case with all types of medical care, the physician must document the clinical need for an OA brace. It is interesting that physicians must routinely document that a patient has knee instability, otherwise Medicare may not approve reimbursement for an OA brace. In my opinion, there can be degenerative changes to the knee and a need for offloading the damaged compartment even when instability is not an issue. This requirement is confusing and sometimes problematic when the physician fails to note that the patient has instability.

Is knee bracing considered a basic standard of care for OA patients?

I think bracing is a basic standard of care, especially since Medicare now requires conservative treatment prior to surgery. However, the American Academy of Orthopedic Surgeons (AAOS) took a neutral position several years ago about the benefits of OA braces, even though there are numerous studies that provide clear evidence of pain relief, increased mobility and other health and quality-of-life enhancements for patients who are prescribed a brace. Meanwhile, other organizations such as the Osteoarthritis Research Society International (OARSI) endorse bracing as conservative, nonsurgical treatment for OA.

Many orthopedic surgeons not only prescribe OA knee braces, they are also dispensing and billing Medicare for OA braces. It is interesting that AAOS hasn’t validated the clinical decisions of orthopedic surgeons who are routinely prescribing and dispensing OA knee braces.

What is the future of OA knee bracing from the perspectives of patients, providers and payers?

The World Health Organization has identified OA as a significant worldwide health issue. As knee pain increases, patients often become less active and their general health can be negatively impacted by secondary medical complications. Obesity, diabetes and heart disease are among the medical conditions that are exacerbated by OA.

An independent study conducted by Stony Brook University of the Townsend Rebel Reliever demonstrated the brace reduced loading forces by an average of 36%. This study was published in two medical journals and presented at several conferences. Patients walked farther with less pain, had increased muscle function in both legs and experienced statistically significant improvements to their quality of life. The patients experienced significant health benefits.

I also know OA braces are an effective treatment for knee pain from personal use. By wearing OA braces after several knee surgeries, I was functionally mobile for two decades before having both knees replaced. OA braces work better for some patients than others. Choosing a brace that is compatible with the patient’s clinical condition and lifestyle helps improve compliance and optimizes outcomes.

Hopefully, providers and payers will allow more patients to wear an OA brace as a precursor to surgery, enabling patients to maintain a higher activity level and realize other health benefits.

Rick Riley is CEO of Townsend Design, which designs, fabricates and distributes orthopedic braces and medical devices that enhance mobility and function for patients who have experienced injuries and physical disabilities.