Spinal Orthosis (HCPCS L0457) Final Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS code L0457. The final edit effectiveness results from May 2021 through August 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 37% for HCPCS L0457.

Top Denial Reasons

  • Documentation was not received in response to the Post-Payment Notification letter.
  • No medical record documentation was received.
  • Documentation does not meet coverage criteria.
  • Medical record documentation is not authenticated (handwritten or electronic) by the author.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.


Last Updated Thu, 26 Aug 2021 13:10:26 +0000