Article Detail - JA DME
Reminder When Providing Orthoses Prior to Surgery
Orthotic devices are not covered unless they meet the coverage criteria outlined in the applicable Local Coverage Determination (LCD) and Policy Article on the date the item is provided. Medical necessity must be met, prior to providing the orthosis.
Items provided before medical necessity begins (for example, before the surgery and the brace is not required until after surgery) will not meet the coverage criteria.
For orthotic devices that require prior authorization (PA) (L0648, L0650, L1832, L1833, and L1851), a PA request should not be submitted prior to the start of medical necessity (for example, before the surgery). If the device is medically necessary after surgery and the medical record documents an emergent need for the device(s), suppliers should submit an expedited request. If an expedited (2-business day) PA request would delay necessary medical care of the beneficiary, append the ST modifier to the claim to bypass PA and provide the brace. These claims will be subject to 100% prepayment review.
For physicians/practitioners subject to non-contract exceptions for competitive bid, please refer to resources below. The KV/J5 modifiers are used if these exceptions apply.
