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 Non-Contract Suppliers and Exceptions under the tips section of the Competitive Bidding page prior to submitting request.
  • The OTS back brace or OTS knee brace must be furnished by the non-contract 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
      • Must be medically necessary and applied for use prior to surgery
    • 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