Same or Similar Denials
Orthotic braces considered to be the “same or similar” to items provided within the reasonable useful lifetime* of the first brace, may be denied. The DME MACs published an article with information about how and when to appeal these denied claims.
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 ).