Jurisdiction A Posts Quarterly Service-specific Prepayment Review Results for Orthoses, Therapeutic Shoes

Noridian Healthcare Solutions, the Jurisdiction A Durable
Medical Equipment Medicare Administrative Contractor (DME MAC), announced the
quarterly results of its service-specific prepayment review for LSOs, KOs, AFOs/KAFOs,
and therapeutic shoes. The quarterly edit effectiveness results from January
through April are as follows:

Spinal Orthoses (L-0648,
L-0650)

·       
The L-0648 (LSO sag r an/pos pnl pre ots) review
involved 500 claims, of which 429 were denied. Based on dollars, this resulted
in an overall claim potential improper payment rate of 86 percent.

·       
The L-0650 (LSO sc r ant/pos pnl pre ots) review
involved 588 claims, of which 534 were denied. Based on dollars, this resulted
in an overall claim potential improper payment rate of 91 percent.

The top reasons for denial are:

·       
Documentation does not support coverage criteria

·       
Documentation was not received in response to
the additional documentation request (ADR)

·       
Proof of delivery (POD) was not received

·       
Claim is the same or similar to another claim on
file

Knee Orthoses
(L-1832, L-1833)

·       
The L-1832 (KO adj jnt pos rigid support) review
involved 175 claims; all were denied. Based on dollars, this resulted in an
overall claim potential improper payment rate of 100 percent.

·       
The L-1833 (KO adj jnt pos r sup pre ots) review
involved 660 claims, of which 598 were denied. Based on dollars, this resulted
in an overall claim potential improper payment rate of 91 percent.

The top reasons for denial are:

·       
Documentation does not support coverage criteria

·       
Documentation was not received in response to
the ADR

·       
Documentation does not support custom-fit
criteria

Ankle-Foot/Knee-Ankle-Foot
Orthosis (L-1970, L-4360, L-4361)

·       
The L-1970 (AFO plastic molded w/ankle j) review
involved 84 claims, of which 54 were denied. Based on dollars, this resulted in
an overall claim potential improper payment rate of 65 percent.

·       
The L-4360 (Pneumati walking boot prefab) review
involved 215 claims, of which 213 were denied. Based on dollars, this resulted
in an overall claim potential improper payment rate of 99 percent.

·       
The L-4361 (Pneuma/vac walk boot pre ots) review
involved 934 claims, of which 676 were denied. Based on dollars, this resulted
in an overall claim potential improper payment rate of 72 percent.

The top reasons for denial are:

·       
Documentation was not received in response to
the ADR

·       
Documentation does not support custom-fit
criteria

·       
POD was not received.

·       
Documentation does not support coverage criteria

Therapeutic Shoes (A-5500)

·       
The A-5500 (Diab shoe for density insert) review
involved 1,159 claims, of which 1,060 were denied. Based on dollars, this
resulted in an overall claim potential improper payment rate of 91 percent.

The top reasons for denial are:

·       
Documentation does not support coverage criteria

·       
Documentation was not received in response to
the ADR

·       
Medical documentation was not received