Common Reasons for Denial

• There was not a Part B practitioner claim on file with the same date of service as this claim for DME item. This item was furnished by a Non-Contract Physician or Other Treating Practitioner, Physical Therapist, or Occupational Therapist for a competitive bid item and must meet certain requirements

Next Step

• Ensure Part B practitioner claim has processed and paid prior to appealing
• A redetermination request may be submitted with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Competitive Bidding requirements prior to submitting request.
  • The OTS back brace or OTS knee brace must be furnished by the physician or other treating practitioner to his or her own patient as part of his or her professional service.
    • Must be office visit, surgery is not included
    • Claims must have the same date of service as the professional office visit or physical/occupational therapy service that is billed to the Part B MAC. The billable office visit is an absolute requirement.
    • Brace must be medically necessary to be worn at home prior to surgery
    • If medical need does not exist until after surgery, a competitive bid contractor must supply brace
  • If these requirements are not met the brace will be denied

How to Avoid Future Denials

• Ensure Part B practitioner claim for office visit is billed with same date of service as providing brace