Why the Policy Article Matters Just as Much as the LCD

What You Need to Know

Policy Articles include key requirements for prosthetic and orthotic (bracing) claims. As a Medicare supplier, you must know and comply with these criteria just as you know and comply with the content of Local Coverage Determinations.

For example, while the LCD for knee orthoses lays out the situations in which those devices are reasonable and necessary - i.e., covered by Medicare - the associated Policy Article explains what distinguishes an off-the-shelf orthosis from a custom-fitted one, and what documentation is required to support either classification. Similarly, while the LCD for lower limb prostheses explains the criteria you must satisfy to fit a K3 knee on a K2 patient, the Policy Article spells out what you must include in your clinical documentation in that situation.

If you focus only on the LCD as part of your claims process, you are missing 50% of what Medicare requires you to know. We regularly see claims denied not because Medicare refuses to cover the prosthetic device or brace, but because the supplier didn’t follow the Policy Article's instructions.

 What this Means for You

You must treat Policy Articles as essential tools in your billing workflow, equal in importance to their related LCDs. Failing to follow a Policy Article's guidance can lead to payment delays, increased audit risk, and potential revenue clawbacks. Conversely, integrating these articles into your claims processes helps ensure compliance, increases operational efficiency, and protects your revenue.

Review both the LCD and its companion Policy Article every time you assess prosthetic or bracing claims processes. And make sure your clinical and billing teams understand the documentation requirements and coding rules outlined in both.

You can access Policy Articles through the links in the "Associated Documents" section at the end of each LCD.