Same or Similar Denials for Orthoses and the Appeals Process - JD DME

Joint DME MAC Article
Posted August 27, 2020

Items that are identical or similar to items previously paid for by Medicare may be provided when the item is lost, stolen, irreparably damaged, or there has been a change in the beneficiary’s medical/physiological condition. The delivery of an orthosis that is the same or similar to an item, previously provided and paid by Medicare, and is within the Reasonable Useful Lifetime (RUL), may be denied on the basis of the RUL. Orthotic devices have a minimum 5-year reasonable useful lifetime (RUL) per the Medicare Benefit Policy Manual (Internet-Only Manual 100-02), Chapter 15, Section 110.2, with the exception of certain knee orthoses which have HCPCS code specific RUL instructions of 1, 2, or 3 years depending upon the HCPCS code. These specific RULs are listed in the Knee Orthoses Policy Article (A52465).

An orthosis that is denied as same or similar may be submitted for a redetermination. The DME MACs will review documentation to determine if the previous item was lost, stolen, irreparably damaged by a specific incident, or if there was a change in the beneficiary’s medical/physiological condition.

Change In Medical Condition

If a claim for an orthosis is denied as same or similar, the supplier may submit a redetermination. If the replacement orthosis is provided due to a change in medical condition, the supplier should submit the following at a minimum (with the redetermination form):

1. Standard written order (SWO);
2. Proof of delivery; and
3. Medical record documentation to substantiate a change of medical/physiological condition.

The medical records should demonstrate the beneficiary’s change in medical/physiological condition necessitating the need for the new orthosis. A focused history and examination of the impacted body part is critical to establishing medical necessity. The medical record should include (but is not limited to):

• the beneficiary’s diagnosis
• prognosis
• duration of condition
• functional limitations
• clinical course
• past experience with related items
• reasons why previous orthotic devices are not functional nor appropriate for the current condition.

The orthotist (supplier) records are a part of the medical record, and are considered in the context of documentation made by the treating practitioner and other healthcare practitioners, to provide additional details to demonstrate the item is reasonable and necessary. The orthotist’s notes are expected to corroborate and provide details consistent with the practitioner’s records. Medical necessity and subsequent payment will not be provided solely based on the orthotist’s documentation. Supplier prepared statements and practitioner attestations, by themselves, do not provide sufficient documentation of medical necessity; even if signed by the ordering practitioner. These documents are not considered part of the medical record.

Lost, Stolen, or Irreparably Damaged

When providing a replacement orthosis which is lost, stolen or irreparably damaged (irreparable damage refers to a specific incident or to a natural disaster (e.g., fire, flood)), and the claim is denied due to same or similar equipment on file, a redetermination may be submitted, and must include documentation of the loss or irreparable damage, as well as a SWO to reaffirm the medical necessity of the item. These redetermination instructions are the same as noted for a change in medical/physiological condition.

Coverage

Certain types of orthoses have specific coverage requirements and these coverage requirements must be met to receive payment. These coverage details are available in the Ankle-Foot/Knee-Ankle-Foot Orthosis, Knee Orthoses, and Spinal Orthoses: TLSO and LSO Local Coverage Determinations and related Policy Articles found on the Medicare Coverage Database (L33686, A52457; L33318, A52465; and L33790, A52500, respectively); additional documentation requirements are addressed in the Standard Documentation Requirements article A55426 .

Information regarding the appeal process including timeframes, addresses, fax numbers, submission forms, and checklists is located on each DME MAC’s website

Jurisdiction A: https://med.noridianmedicare.com/web/jadme/claims-appeals
Jurisdiction B: https://www.cgsmedicare.com/jb/claims/appeals/index.html
Jurisdiction C: https://www.cgsmedicare.com/jc/claims/appeals/index.html
Jurisdiction D: https://med.noridianmedicare.com/web/jddme/claims-appeals

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