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Issue Number - Name
0155-Upper Limb Orthoses within the Reasonable Useful LIfetiime Limit
Review Type
Automated
Provider Type
DME Physician/DME Supplier
RAC Region/MAC Jurisdiction
Region 5
All DME MACs
Date Approved
04/02/2019

Description

Claims for upper limb orthoses with dates of service within 5 years of the date of service of a previously paid upper limb orthoses for the same beneficiary, for HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.

Affected Codes

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 and L3995

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
2. Social Security Act, Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment.
3. 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
4. 42 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
5. 42 CFR §405.986- Good Cause for Reopening
6. 42 CFR §414.210- General Payment Rules
7. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 110.2.C- Replacement
8. 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