Article Detail - JA DME

The most common denial for AFOs/KAFOs is Reason Code 151 | Remark Code M3. To avoid this denial in the future, it's important to understand the reasons behind it.

This denial occurs when the item billed is considered the same as or similar to an item the beneficiary previously received that appears in their history. It's crucial to determine whether the initial item was lost, stolen, irreparably damaged, or if there was a change in the beneficiary's medical condition requiring a different type of orthosis.

To appeal this denial, a redetermination (first-level appeal) request can be submitted with all relevant supporting documentation to justify the need for a new orthosis. The Noridian Medicare Portal (NMP) is recommended for this submission, as it's the quickest and easiest method.

To prevent this denial in the future, it's recommended to check if the beneficiary already has a same or similar item using the NMP or by calling the IVR. If they do, and the end of the reasonable useful lifetime (RUL) hasn't been reached, an Advance Beneficiary Notice of Noncoverage (ABN) should be provided to the beneficiary.

Additionally, Noridian's Denial Code Resolution webpage and tool can be used to look up any reason and remark code, understand what went wrong with the claim submission, how to resolve the denial, and how to avoid it in the future.