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 AFOs and therapeutic shoes. The quarterly edit effectiveness results from October 2016 through January 2017 are as follows:
AFOs (L-1970, L-4360, and L-4361)
- The L-1970 (ankle-foot orthosis, plastic with ankle joint, custom fabricated) review involved 275 claims, of which 218 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 79 percent.
- The L-4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting & adjustment) review involved 667 claims, of which 658 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 982 claims, of which 648 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 65 percent.
The top reasons for denial are:
- Documentation does not support custom fit criteria
- Documentation was not received in response to the Additional Documentation Request (ADR) letter
- Proof of delivery (POD) was not received
- Documentation does not support coverage criteria
- Medical record documentation is not authenticated (handwritten or electronic) by the author
Therapeutic Shoes (A-5500)
The A-5500 (Diab shoe for density insert) review involved 2,085 claims, of which 1,999 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 96 percent.
The top reasons for denial are:
- Documentation does not support coverage criteria
- Documentation was not received in response to the ADR letter
- Medical record documentation was not received
