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Issue Number - Name
0013 - Complex Comprehensive Medical Necessity AFO & KAFO Orthoses
Review Type
Complex
Claim Type
DME by Supplier
Region and State
RAC 5
All States
Date Approved
2017-07-05

Description

Ankle-Foot Orthosis and Knee-Ankle-Foot Orthosis must meet basic coverage criteria and subsequent, whether at initial purchase or at any point during a rental period as outlined in CMS Publications and Local Coverage Determination (LCDs) for AFO/KAFO Orthoses. Medical documentation will be reviewed to determine that services were reasonable and necessary.

Affected Codes

  • ICD-9 diagnosis code 728.71
  • ICD-10 diagnosis code M72.2 

Applicable Policy References 

  • 42 Code of Federal Regulations, 414.402
  • Social Security Act, Section 1833 (e)
  • Social Security Act, Section 1842 (p)(4)
  • Social Security Act, Section 1847 (a)(2)
  • Social Security Act, Section 1834 (h)(1)(F)(i), (ii)
  • Social Security Act, Section 1861 (s)(9)
  • Social Security Act, Section 1834 (a)(1)(E)(i), (ii) and (v)
  • Social Security Act, Section 1834 (a)(7)(C)(i), (ii) and (iii)
  • Social Security Act, Section 1834 (a)(4)
  • 42 CFR, 424.57(12)
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2(C)
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, Section 100.2
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, 4.26.1
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2, 5.2.1, 5.2.3, 5.2.4, 5.2.7, 5.7, 5.8 and 5.9
  • CMS Local Coverage Determinations, L142, L1157, L27229, L11527 (superseded issues prior to 10/1/15)
  • CMS Local Coverage Determination, L33686, DOS on/after 10/1/15
  • CMS Policy Article, A19800, A19806, A1947227, A19885
  • CMS Policy Article, A52457