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Issue Number - Name
0144-Off-the-Shelf-Knee Orthosis
Review Type
Complex
Claim Type
DME by Supplier, DME by Physician
Region and State
RAC 5
All DME
Date Approved
02/05/2019

Description

Prefabricated Off the Shelf Knee Orthoses may have been provided to beneficiaries where all Medicare coverage requirements were not met.  This review will determine if the orthoses is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity requirements will be denied

Affected Codes

L1812, L1820, L1830, L1831, L1833, L1836, L1848, L1850, L1851 and L1852

Applicable Policy References

Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)-Exclusions from Coverage and Medicare as a Secondary Payer
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834-Special Payment Rules
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(j)-Requirements for Suppliers of Medical Equipment and Supplies
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1842(p)(4)-Provisions Relating to the Administration of Part B
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1861(s)-Medical and Other Health Services Definitions
42 CFR, Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
42 CFR, Section 405.986-Good Cause for Reopening
42 CFR, Section 424.57-Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
42 CFR, Section 424.57(c)-Application Certification Standards
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3-Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3.8-No Response or Insufficient Response to Additional Documentation Requests
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4-Program Integrity, Section 4.26 Supplier Proof of Delivery Documentation Requirements 
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15-Covered Medical and Other Health Services, Section 110-Durable Medical Equipment-General
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations
CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD), L33318-Knee Orthoses, Effective Date 10/01/2015, Revision Effective Date 10/16/2017
CGS Administrators LLC, and Noridian Healthcare Solutions LLC, Local Coverage Article, A52456-Knee Orthoses, Effective Date 10/01/2015, Revision Effective Date 01/01/2017
CGS Administrators, LLC, and Noridian Healthcare Solutions LLC, Local Coverage Article-Standard Documentation Requirements for All Claims Submitted to DME MACs, A55426-Effective 01/01/2017, Revised 08/28/2018