Pre-Authorization of CAM Boots Used for Off-Loading

A recent posting in another podiatry publication advocated for use as an off-loading device for foot ulcers and their prior authorization, leading to the questions, Can you confirm this is correct? I thought CAM walkers were not covered for offloading? If so why must I obtain pre-authorization?

You are correct that CAM boots and AFOs, except for a CROW Boot L4631, are statutorily non-covered for off-loading foot ulcers. The underlying condition causing the ulcer may be covered. For example, a dislocation of a Lis-Francs joint resulting in a pressure ulcer with an acute Charcot foot, is covered for a pneumatic CAM boot to immobilize the dislocation and provide immobilization and compression. However, off-loading the ulcer is not considered a covered diagnosis for the CAM boot.

Starting October 15, due to abuse, new providers (those on probation for one year) will be required to obtain prior authorization for pneumatic CAM boots L4360/L4361) prior to billing. One exception to the prior authorization requirement is for those pneumatic CAM boots needed in an urgent situation where prior authorization can’t wait. Urgent scenarios such as fracture or dislocation are an example of where the ST modifier can be bypassed and billed only with a KX and site (RT or LT) modifier. 

Use of the “ST” or stat modifier along with the KX and site modifiers will eliminate the requirement for obtaining prior authorization. However, those claims which bypass the prior authorization process will most likely be required to be pre-reviewed by Medicare prior to payment.

This new prior authorization process for pneumatic CAM walkers does not apply to all providers, only those on probationary status. However, it serves as a wakeup call for all providers that Medicare has added CAM boots to the master list of codes it is watching for potential abuse. 

—Paul Kesselman, DPM