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Linda Collins Blogger

How Often Can You Replace a Knee Orthoses?

Posted by Linda Collins | September 20, 2017

Medicare defines a Reasonable Useful Lifetime (RUL) for most orthotic items.

RUL is the expected minimum lifespan for the item. It starts on the initial date of service and runs for the defined length of time. If a same or similar item is provided during the RUL of an item already in the beneficiary's possession, Medicare will deny it as "same/similar or duplicate."

Knee Orthoses have defined RULs of 1-3 years (Local Coverage Article – Knee Orthoses – Policy Article A52465) All other orthoses have an RUL of five years.

Medicare computes the useful lifetime from when the equipment is delivered to the beneficiary, not the equipment's age. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the RUL, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. 

Replacement during the "reasonable useful lifetime," is covered if the item is lost, stolen, irreparably damaged or there is a significant physical change in the patient which prevents continued use of the existing brace. 

The following chart reflects the reasonable useful lifetime of prefabricated Knee Orthoses:

HCPCS Years RUL
L18101
L18121
L18201
L18301
L18312
L18322
L18332
L18363
L18433
L18453
L18502
L18513
L18523

The reasonable useful lifetime of custom fabricated orthosis is 3 years

For a replacement to be covered, a new Detailed Written Order is needed to reaffirm the medical necessity of the item. The physician's medical record must indicate the continued need and use of the item and the reason the current brace is not useable.  In the case of a lost or stolen item, consider including copies of police records or a patient's written statement.

Replacement for other reasons, including but not limited to irreparable wear, during the RUL period will be denied as non-covered. 

The applicable replacement modifiers are:

  • RA- Replacement of a DME, Orthotic or Prosthetic Item
  • RB- Replacement of a Part of a DME, Orthotic or Prosthetic Item Furnished as Part of a Repair

NOTE: Use of the RA modifier implies that the entire DMEPOS item (base equipment) is being replaced. If you replace a specific part but not the base equipment, the service is considered a repair and the RB modifier should be used on the claim.

What does this mean for you?

When replacing an orthosis, (1) make sure you check the RUL, (2) use the appropriate modifier, and (3) make sure both your documentation and the prescribing physician's contain all required information to justify the need for a new brace. In the absence of strong documentation, you may consider using an ABN. 

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