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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

99%

L1960: ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED

76%

L1970: ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED

72%

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

64%

E0185: GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH

41%

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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

92%
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

60%

 
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

53%

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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 56%

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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%

 

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 100%
LO: L0625, L0626, L0627, L0641, L0642 100%
LSO: L0628- L0640, L0643, L0648 99%

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

100%

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 99%

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

74%

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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

 

 

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 Jan 13, 2017