Due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor, NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has announced that it will be initiating a widespread prepayment probe of claims for two lumbar-sacral orthoses, as follows:
- L-0631: Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.
- L-0637: Llumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.
For information regarding coverage criteria and documentation requirements, read the Local Coverage Determination (LCD) for Spinal Orthoses: TLSO and LSO, L11470, and Policy Article A23663.
