Same or Similar Denials

Linda Collins
04-26-2022
Blog

Learn about the redetermination process as the first level of appeals.

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
  • Orthotist/Supplier documentation supporting medical necessity
  • Physician medical records supporting medical necessity

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.