Common Reasons for Denial

• There was not a Part B practitioner claim on file with the same date of service as this claim for DME item. This item was furnished by a Non-Contract Physician or Other Treating Practitioner, Physical Therapist, or Occupational Therapist for a competitive bid item and must meet certain requirements

Next Step

• Appeal claim, ensure Part B practitioner claim has processed and paid prior to appealing
• A redetermination request may be submitted with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Competitive Bidding requirements prior to submitting request.
  • The OTS back brace or OTS knee brace must be furnished by the physician or other treating practitioner to his or her own patient as part of his or her professional service.
    • Brace must be medically necessary to be worn at home prior to surgery
    • Claims must have the same date of service as the office visit or surgery date
    • Or if furnished as part of an unbillable follow-up visit during a surgical post-operative period related to recovery, the claim should be billed with the same date of service or noted as applying to the same date as the surgery
  • Claim must include narrative of surgery date. Narrative example DOS 05/01/23
    • Item 19 of the 1500 claim form or the 2400/NTE segment of an electronic claim

How to Avoid Future Denials

• Ensure Part B practitioner claim for office visit is billed with same date of service as providing brace
  • Claims must have the same date of service as the office visit or surgery date
  • Or if furnished as part of an unbillable follow-up visit during a surgical post-operative period related to recovery, the claim should be billed with the same date of service or noted as applying to the same date as the surgery
  • Claim must include narrative of surgery date. Narrative example DOS 05/01/23
    • Item 19 of the 1500 claim form or the 2400/NTE segment of an electronic claim