The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have published a joint article, Same or Similar Denials for Orthoses and the Appeals Process, to each jurisdiction’s website. The article reads in part:
“Items that are identical or similar to items previously paid for by Medicare may be provided when the item is lost, stolen, irreparably damaged, or there has been a change in the beneficiary’s medical/physiological condition. The delivery of an orthosis that is the same or similar to an item, previously provided and paid by Medicare, and is within the Reasonable Useful Lifetime (RUL), may be denied on the basis of the RUL. Orthotic devices have a minimum 5-year reasonable useful lifetime (RUL) per the Medicare Benefit Policy Manual (Internet-Only Manual 100-02), Chapter 15, Section 110.2, with the exception of certain knee orthoses which have HCPCS code specific RUL instructions of 1, 2, or 3 years depending upon the HCPCS code. These specific RULs are listed in the Knee Orthoses Policy Article (A52465).
“An orthosis that is denied as same or similar may be submitted for a redetermination. The DME MACs will review documentation to determine if the previous item was lost, stolen, irreparably damaged by a specific incident, or if there was a change in the beneficiary’s medical/physiological condition.
“The orthotist (supplier) records are a part of the medical record, and are considered in the context of documentation made by the treating practitioner and other healthcare practitioners, to provide additional details to demonstrate the item is reasonable and necessary. The orthotist’s notes are expected to corroborate and provide details consistent with the practitioner’s records. Medical necessity and subsequent payment will not be provided solely based on the orthotist’s documentation. Supplier prepared statements and practitioner attestations, by themselves, do not provide sufficient documentation of medical necessity; even if signed by the ordering practitioner. These documents are not considered part of the medical record.”
Information regarding the appeal process is located on each DME MAC’s website.
· Jurisdiction A: https://med.noridianmedicare.com/web/jadme/claims-appeals
· Jurisdiction B: www.cgsmedicare.com/jb/claims/appeals/index.html
· Jurisdiction C: www.cgsmedicare.com/jc/claims/appeals/index.html
· Jurisdiction D: https://med.noridianmedicare.com/web/jddme/claims-appeals
To read the article on Noridian’s website, visit https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2020/same-or-similar-denials-for-orthoses-and-the-appeals-process.
To read the article on the CGS website, visit www.cgsmedicare.com/jc/pubs/news/2020/08/cope18619.html