Description
Claims for upper limb orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously-paid identical upper limb orthosis (identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.
Affected Code(s)
L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984, L3995
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5. 42 Code of Federal Regulations (CFR), §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
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
8. 42 CFR §405.986- Good Cause for Reopening
9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions
10. 42 CFR §414.210(f)- Payment for Replacement of Equipment
11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110.2.C- Repairs, Maintenance, Replacement, and Delivery and §130- Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
15. Annual HCPCS Manual