Just went through a ALJ hearing and received a “Fully Favorable” judgment,
which with the documentation provided it should have never had to go that
extent. I just want to remind people please fight these audits all the way
through and make sure you look at the rational behind their denial and look
at the terms they are trying to use, make sure they are citing LCD/Policy
that was valid at the time of treatment and fight them with their own words.
In my case we were appealing bilateral KAFOs from 2016 with excellent
documentation from physician. In the end they challenged meeting custom
criteria which was easily disputed by physician documentation but oddly
enough they were trying to stick it to me using the verbiage which is being
applied to OTS vs Custom fit devices as far as there were not significant
modifications at the time of delivery. This verbiage does not apply to
custom made devices and therefore cannot be used and I should not be
penalized for delivering an orthosis that fit well. Bottom line get
documentation and read up on policy and we can beat these guys.
Chris Wells CPO/L
Williams O&P
PS.. Please don’t respond with” the auditors follow this list so watch what
you say”.
