Noridian, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction A, posted results for quarterly service-specific prepayment reviews for knee orthoses and therapeutic shoes. The quarterly edit effectiveness results from July through October 2016 are as follows:
Knee Orthoses (L-1832 and L-1833)
The L-1832 (KO adj jnt pos rigid support) review involved 164 claims, of which 163 were denied. The L-1833 (KO adj jnt pos r sup pre ots) review involved 552 claims, of which 535 were denied. Based on dollars, these resulted in overall claim potential improper payment rates of 100 percent and 98 percent, respectively.
The top reasons for denial are:
- Documentation does not support coverage criteria
- Documentation was not received in response to the Additional Documentation Request (ADR) letter
- Documentation does not support custom fit criteria
- Medical documentation was not received
Therapeutic Shoes (A-5500)
The A-5500 (Diab shoe for density insert) review involved 1,335 claims, of which 1,283 were denied, resulting in an overall claim potential improper payment rate of 97 percent.
The top reasons for denial are:
- Documentation does not support custom molded shoe coverage criteria
- Medical documentation was not received
- Documentation was not received in response to the ADR letter
