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Complex Review Notifications and Results

Service Specific Post-Payment Reviews - Noridian DME Medical Review currently does not have any active Post-Payment Reviews.

Service Specific Pre-Payment Reviews - Service Specific Pre-Pay Reviews conducted by Noridian DME Medical Review are used to determine the extent of potential problem areas across multiple suppliers and monitor corrective action measures implemented to reduce improper payments.

Ankle Foot/Knee-Ankle-Foot Orthosis

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
L4361: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 68%
L4360: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 98%
L1960: ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED 75%
L1970: ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED 71%
L1902, L1904, L1907, L4350    
L1900, L1906, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4396, L4397, L4398    
L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136    
L4360, L4361, L4370, L4386, L4387, L4398, L4631    

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Continuous Positive Airway Pressure (CPAP) Devices

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0601: CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE. FIRST MONTH OF BILLING 39%  
E0601: CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE. FOURTH THROUGH THIRTEENTH MONTH OF BILLING 50%

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Diabetic Supplies

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
A4253: GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS.    

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Enteral Nutrition

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
B4150: ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT 42%
B4154: ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT 43%

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External Breast Prosthesis

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
L8030: BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE 61%

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External Infusion Pumps

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
J1817: INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS 100%
J2260: INJECTION, MILRINONE LACTATE, 5 MG 51%

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Group 1 Pressure Reducing Support Surfaces

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0181: POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY 72%
E0185: GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH 63%

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Group 2 Pressure Reducing Support Surfaces

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0277: POWERED PRESSURE-REDUCING AIR MATTRESS 68%

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Hospital Beds

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0250: HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS 58%
E0260: HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS 74%

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Immunosuppressive Drugs

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
J7507: TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG 60%
J7517: MYCOPHENOLATE MOFETIL, ORAL, 250 MG 64%
J7518: MYCOPHENOLIC ACID, ORAL, 180 MG 56%
J7520: SIROLIMUS, ORAL, 1 MG 64%

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Knee Orthosis

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
L1832: KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 99%
L1833: KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF 93%
L1843: KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 99%
K0901, K0902, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1860    

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Lower Limb Prostheses

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
L5980: ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM 88%
L5981: ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL 81%
L5987: ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON 79%
L5673: ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM 79%
L5301: BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM 80%

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Manual Wheelchairs

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
K0001: STANDARD WHEELCHAIR 65%
K0003: LIGHTWEIGHT WHEELCHAIR 79%
K0004: HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 64%

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Nebulizers

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
J7682: TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS 72%
J7686: TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG 55%
Q4074: ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS 20%  

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Negative Pressure Wound Therapy

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E2402: NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE 52%

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Osteogenesis Stimulators

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0747: OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL APPLICATIONS 77%
E0748: OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS 56%

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Oxygen and Oxygen Equipment

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0439: STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING 57%
E0434: PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING 71%
E1390: OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 53%
E0431: PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING 62%

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Parenteral Nutrtition

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
B4185: PARENTERAL NUTRITION SOLUTION, PER 10 GRAMS LIPIDS 94%
B4197: PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, 74 TO 100 GRAMS OF PROTEIN - PREMIX 94%

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Patient Lifts

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0636: MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS 100%

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Power Mobility Devices

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
K0823: POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS 54%

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Respiratory Assist Device (RAD)

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0470: RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) 66%

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Spinal Orthoses: TLSO and LSO

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
TLSO: L0450, L0452, L0454-L0458, L0460, L0462, L0464, L0466- L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490- L0492 100%
SO: L0621, L0623 97%
LO: L0625, L0626, L0627, L0641, L0642 100%
LSO: L0628- L0640, L0643, L0648 100%
L0631: LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 94%
L0637: LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 96%
L0648: LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF 78%
L0650: LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF 83%

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Therapeutic Shoes and Inserts

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
A5500: FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI- DENSITY INSERT(S), PER SHOE 72%

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Transcutaneous Electrical Nerve Stimulator (TENS)

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0730: TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION
  • 100%
E0720: TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION    

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Urological Supplies

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
A4326: MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH 85%  
A4351: INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH 57%
A4353: INTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIES 85%
A4357: BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH 78%
A4358: URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, EACH 67%

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Vacuum Erection System

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
L7900: MALE VACUUM ERECTION SYSTEM 100%

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Ventilators

Review Criteria Current Error Rate Service Specific Review Notification Current Review Results
E0464: PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) 100%
E0466: HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL) 76%

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Last Updated Feb 17, 2017