Hi All,
I should have been clear that we do have an Rx, detailed prescription, practitioner notes, and photos of the damaged liners that are over a year old. Apparently it doesn’t matter what it says in the LCD. Can anyone tell me if they have been successfull in overturning a denial at the point of redetermination, and if so, how? Our physicians are becoming very annoyed with the amount of paperwork they are being asked to provide especially for supplies that are supposed to be covered under the original Rx. Anyway, thanks to all who responded. One person asked that I not share her name so I have removed all the names from the replies.
Cindy Anderson
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When answering a redetermination it is important to have as many facts in the record as possible. In addition they are looking into the overuse of liners. Most patient’s liner wearout in 12 months of regular use on an active patient and most warranties are 12 months some are 6. If the patient has received multiple liners previously during the 12 month period and now you are supplying additional liners this gets flagged and as something that could be an over use. I have gone to the policy of getting RX for replacement liners with a medical justification/medical necessity explanation. The information you provide medicace is usually enough as long as this patient has not received multiple liners in the last 6 months to a year. I know the HOA files in most electronic programs are only 80 characters but when you are sending chart notes to back you up it is always better to have a good medical justification and or necessity for replacement.
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Other than minor repairs under L7510/L7520, we requires new documentation for all prosthetic services. Whenever a patient calls saying they need replacement socks, liners, suspension sleeves, etc, we require they have the face-to-face with their physician and obtain a script and complete clinical documentation from the referring physician. If they obtain a prescription for socks and the referring physician writes “as needed” on the prescription then we will provide replacement socks for the patient under the original order, but we will not accept that for high dollar items like liners and suspension sleeves. I have had to appeal things that we have provided under the original order, quoting the LCD, providing a copy of the LCD, etc. If you don’t have supporting documentation from the physician’s medical record, no matter what you say, it’s likely to not matter and you will end up taking it all the way through the appeal process.
When you go to Redetermination, I would provide a copy of the original doctor’s order and original order’s clinical documentation, state the date that the original order was delivered and paid for by Medicare and state that because Medicare paid for the original, based on the LCD (quote directly out of it), this is “a replacement component that is required due to irreparable damage and that it should be reimbursed without a physician’s order as long the prosthesis as originally ordered still fills the beneficiary’s medical needs”. I would also include all of your practitioner’s very detailed clinical documentation as to why the replacement liners are necessary. Even with that, it is likely that it will deny at Redetermination and you will have to go to Reconsideration. There is a chance that at Reconsideration it might be overturned and Medicare required to pay, but I wouldn’t hold my breath. I have appeals all the way up through the 4th level Medicare Appeals Council at this point for things I have provided copious amounts of notes and proof of medical necessity for repairs and such that aren’t supposed to require physician orders/documentation and yet they still have not been paid.
Anyway, all that to say, don’t believe a word the LCD says and start making your patient’s go to their doctor and get all of the same required paperwork for everything you do except for minor repairs under L7510/L7520 (and do not bill more than 2 hours labor (more than 8 units of L7520) because it will automatically be denied as exceeding allowed number of units, even though there is no stated allowed amount of units for L7520).
Hope this helps you. If you have any other questions based on this, feel free to email me. I am totally open to giving any helpful info I can when it comes to appeals and if I can’t answer a question, I will try to ask some of my contacts if they can answer it.
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we called the help desk on this one, they said that they will only pay for 2 liners per year… not in the LCD but that is what they are telling us. ugh
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I am interpreting the tea leaves on liner replacements that 1. end of warranty period is not a sole reason to replace, 2. wear and torn reason, you better have MD documentation that speaks to that.
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Even though they may tell you that certain things are covered if the patient needs them doesn’t mean they will just pay up front, you do have to file a redetermination as soon as possible. I would attach any notes from the practitioner stating the need for the replacements along with any pictures of torn or worn items as well as the explanation of benefits circle the denied codes on there. If you can find the exact words from the webinar in their LCD stating that they can be replaced, print and attach that as well, send the original date of when the first ones were delivered on the delivery slip. This is what will probably happen: the redetermination will come back unfavorable, then you need to file a C2C/QIC 2nd level of appeals restating everything and sending once again, everything you sent with the first appeal, this will probably come back either way, if it still denies, send everything once again with the alj form for 3rd level of appeals, you will then receive a letter stating that they are behind in appeals and will get to your case within 28 months, yes 28 months, at the alj level you will more than likely win. We’ve been doing this for 2 years now and haven’t lost one yet, but the whole process is ridiculous.
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As far as I know, and we’ve questioned this quite often with our contractor, a prescription is needed for liners. Sleeves and socks ARE covered underthe original RX for a replacement socket or full prosthesis. We do not use a replacement modifier with liners. I believe the RP modifier is optional at this point.
Hope this helps!
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They are being denied across the board from what I see here and what I am hearing. The LCD states no more than two per prosthesis at the same time HOWEVER Medicare is stating it is no more than 2 per prosthesis PERIOD. You can bill for additional however they will be denied, you will have to appeal and prove why they were needed. I too filed a re-determination and stated irreparable damage along with our Prosthetist chart notes stating they were worn out and Medicare DENIED the appeal stating we did not have sufficient Physician Documentation. UGH!!!!
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sorry to tell you this, but you have to get a new scrip every time and the patient also has to go and see the doc every time and the doc has to document it : ) wish you luck with this.
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I just had a denial on the liners as well. I am interested in any reply’s as to what to send.
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I believe a new prescription is needed for a liner but not socks and sleeves. I normally try to take pictures of old worn out liners when replacing. sleeves as well. a picture is worth a thousand words. I would be interested in seeing answers.
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Additional inserts (either custom fabricated or prefabricated) provided at the time of initial issue or replacement socket inserts are coded L5673 and L5679, whichever is applicable.
No more than two of the same socket inserts (L5654-L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time.
….Per Medicare….
We have not yet experienced denials for this but would like responses to this as well. Are they giving you a specific reason for denial? Did you take pictures of the torn/damaged liners? That always helps to prove your case. Good luck.
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