Top Non-Affirmation Reasons for Orthotics - JD DME

The Jurisdiction D, DME MAC, Medical Review Department Prior Authorization (PA) review findings for select Orthotics are provided below.

Top Reasons for Non-Affirmation: October - December 2023

• The medical record documentation does not demonstrate an objective description of joint laxity. This accounts for 37% of non-affirmations.
• The medical record documentation indicates the item is needed during post-operative recovery; however, the surgery has not yet taken place. This accounts for 29% of non-affirmations.
• The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s). This reason accounts for 14% of non-affirmations.
• The documentation demonstrates the requested item has been delivered and is therefore not eligible for Prior Authorization. This reason accounts for 14% of non-affirmations.

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Knee Orthoses Local Coverage Determination L33318 and Spinal Orthoses: TLSO and LSO Local Coverage Determination L33790.

Suppliers can also view resources related to applicable HCPCS codes, submitting PA requests, documentation requirements, educational resources and CMS Resources via the Required Prior Authorization Programs webpage.

Noridian provides education via supplier workshops, training opportunities, and presentations

Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

Policy Education

The medical record documentation does not demonstrate an objective description of joint laxity.

For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

The medical record documentation does not support the beneficiary has had a recent injury or surgical procedure on the knee(s).

A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had a recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related Policy Article.

The medical record documentation indicates the item is needed during post-operative recovery; however, the surgery has not yet taken place.

Medicare does not cover an orthotic device dispensed to a beneficiary prior to the time at which the beneficiary undergoes the procedure that makes necessary the use of the device. Moreover, the need for the device cannot be clearly established until the procedure that makes its use possible is successfully performed.

For Knee Orthoses:
A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had a recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related Policy Article.

For Spinal Orthoses:
A spinal orthosis is covered when it is ordered for one of the following indications:

1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.

The documentation demonstrates the requested item has been delivered and is therefore not eligible for prior authorization.

Prior to furnishing the item to the beneficiary and submitting the claim for processing, a requester must submit a prior authorization request. The request must include evidence that the item complies with all applicable Medicare coverage, coding, and payment rules. Consistent with 42 CFR §?414.234(d), such evidence must include the order, relevant information from the beneficiary's medical record, and relevant supplier-produced documentation. It is a condition of payment to have the prior authorization prior to providing the item.