Description
Claims for canes, crutches, and/or walkers billed within the five-year reasonable useful lifetime of a previously reimbursed item billed with an identical HCPCS for the same beneficiary will be denied as the reasonable useful lifetime requirement has not been met.
Affected Code(s)
E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149
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 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
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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination LCD L33733- Canes and Crutches; Effective 10/01/2015; Revised 01/01/2020
15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article LCA A52459- Canes and Crutches- Policy Article; Effective 10/01/2015; Revised 01/01/2020
16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination LCD L33791- Walkers; Effective 10/01/2015, Revised 01/01/2020
17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article LCA A52503- Walkers- Policy Article; Effective 10/01/2015; Revised 04/01/2024
18. HCPCS Level II Codebook