Competitive Bidding
Under the next round of Competitive Bidding, Round 2021, Physicians, physician assistants, nurse practitioners, clinical nurse specialists, physical therapists and occupational therapists may provide OTS back braces and knee braces to their own patients as part of their professional services. Payment will be based upon the payment amounts determined by the Competitive Bidding Program.
Hospitals may provide OTS back braces and OTS knee braces to patients during an admission or on date of discharge. This does not apply to a hospital owned DMEPOS supplier. A hospital owned DMEPOS supplier must be awarded a CB contract in order to provide the braces.
A SNF located within a CBA must be awarded a contract to provide braces to their patients.
Additional information about Round 2021 Competitive Bidding may be found here.
A brace that is considered “same or similar” to a brace previously dispensed and paid for by Medicare, may be provided when:
- The original item is lost, stolen, or irreparably damaged, OR
- There is a change in the patient’s medical/physiological condition.
If you are providing a brace to a patient for a change in medical condition, and your claim is denied, you may submit a redetermination to the DME MAC. The following documents are required as part of the redetermination submission:
- Standard Written Order
- Proof of Delivery
- Medical Documentation detailing the patient’s change of condition
The medical records should include:
- Patient’s diagnosis, past and current
- Prognosis
- Duration of condition
- Functional limitations
- Reasons why previous brace is not functional for current condition
What does this mean for you?
Check the DME MAC website to determine if a patient has previously received a same or similar item.
If you receive a denial, and you have substantial documentation to show there is a change in the patient’s medical condition, which substantiates the new brace, immediately file a redetermination.
You may find out more about the redetermination process by visiting the appropriate DME MAC site.
- Jurisdiction A: https://med.noridianmedicare.com/web/jadme/claims-appeals
- Jurisdiction B: https://www.cgsmedicare.com/jb/claims/appeals/index.html
- Jurisdiction C: https://www.cgsmedicare.com/jc/claims/appeals/index.html
- Jurisdiction D: https://med.noridianmedicare.com/web/jddme/claims-appeals
*Orthotic devices have a minimum 5-year reasonable useful lifetime (RUL) per the Medicare Benefit Policy Manual (Internet-Only Manual 100-02), Chapter 15, Section 110.2, with the exception of certain knee orthoses which have HCPCS code specific RUL instructions of 1, 2, or 3 years depending upon the HCPCS code. These specific RULs are listed in the Knee Orthoses Policy Article (A52465 ).