Description
Claims for Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously paid identical Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses (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)
L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2006, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4631
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, Section 110.2 – Repairs, Maintenance, Replacement, and Delivery (C) – Replacement Medicare Benefit Policy
12. 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. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686: Ankle-Foot/Knee-Ankle-Foot Orthosis; Effective 10/01/2015; Revised 01/23/2024
16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52457: Ankle-Foot/Knee-Ankle-Foot Orthosis- Policy Article; Effective 10/01/2015; Revised 01/23/2024
17. HCPCS Level II Codebook