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Issue Number - Name
0148-Knee Orthosis within the RUL
Review Type
Automated
Claim Type
DME by Supplier, DME by Physician
Region and State
RAC 5
All DME MACs
Date Approved
03/05/2019

Description

Claims for knee orthoses with dates of service within 90 days of the date of service of a previously paid knee orthoses for the same anatomical site will be denied as the reasonable useful lifetime requirement has not been met.

Affected Codes

L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852 and L1860

Applicable Policy References

Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
Social Security Act, Section 1834 (a), Payment for Durable Medical Equipment
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment
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 414.210-General Payment Rules
CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.C
CGS Administrators LLC, and Noridian Healthcare Solutions LLC, 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 A52465 Knee Orthoses, Effective Date 10/01/2015, Revision Effective Date 01/01/2017
CGS Administrators LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs, Effective 01/01/2017, Revised 08/28/2018