Article Detail - JD DME

Devices provided prior to the start of medical necessity (for example, before surgery when the brace is not required for use until after), will not meet the coverage criteria. After surgery, if there is documentation of the medical necessity for the orthotic device(s), a brace may be considered for coverage. Keep in mind there are many other payment rules related to providing braces.

For orthotic devices that require prior authorization (PA) (L0648, L0450, L1832, L1833, and L1851), do not submit PA requests prior to the start of medical necessity. After surgery, if the medical record documentation shows an emergent need for the device(s), submit an expedited request. If an expedited request is not feasible, suppliers may append the ST or KV modifier to the claim to bypass PA. These modifiers may only be used under certain circumstances. Please review the rules concerning correct use of the ST and KV modifiers to avoid denials. Information can be found on the Orthotics webpage, Prior Authorization for Orthoses webpage, and/or the Competitive Bidding webpage. Claims submitted with the ST or KV modifier are subject to prepayment review. Importantly, once a claim has been submitted with the ST or KV modifier it should not be submitted for PA.

If the item is subject to a competitive bid exception, refer to the Noridian Competitive Bidding webpage under "Non-Contract Suppliers and Exceptions" in the TIPS section for guidance and resources.