Saturday, May 25, 2024

broken AFO claim denied despite physician documentation

Laura Ramsower


I am looking for some advice about a claim that we have that will be heard by the ALJ soon. We have a patient whose Toe-Off cracked about 2.5 years after receiving it. It cracked on the baseplate, near the junction of the strut. The physician documented the cracked AFO and documented that the patient has weakness of the foot and ankle (foot drop) and that the patient will benefit functionally from the AFO so the AFO needed to be replaced. Our Orthotist’s notes also document that the AFO is cracked and is unable to control the patient from plantarflexing.

Medicare and each level of appeal continues to deny the appeal. This last determination from QIC said “The supplier argues the previous orthosis was cracked. However, the documentation provided does not indicate that the previous orthosis was damaged by a specific event. In addition, the records do not contain documentation supporting the beneficiary had a significant change in medical condition or the prior orthosis was lost or stolen. Therefore, Medicare coverage for the item is not allowed.”

Is there no longer the rule that if it costs more than 60% of the replacement cost to repair the item, that the patient is eligible to receive a new item? As you all know, repairing a Toe-Off is not feasible and replacement is the only option once the footplate or strut has cracked and rendered the AFO ineffective. QIC is arguing that since there was not a specific event that damaged the item, that Medicare is not responsible for paying for the replacement. Usually cracks like this occur over time, not from a specific fall or incident. Have any of you had a denial like this and were you successful at overturning the denial? If so, can you give me any tips of what documentation you provided to have the denial overturned?

Thank you,
Laura Ramsower


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