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Linda Collins Blogger

L5845 Denial Trend

Posted by Linda Collins | January 24, 2019

​Recently we have received notice that several private payers are denying L5845 (addition, endoskeletal, knee-shim system, stance flexion feature, adjustable) and citing Medicare LCD and PA as basis for denial. If you do receive this denial, be sure to appeal immediately. There are valid reasons for the basis of the appeal, including:

  • The LCD (L33787) and PA (52496) do not mention that L5845 is not to be billed as an add-on code for mechanical knees. If the payer states this is listed in the LCD or PA, ask them to point out the exact reference.
  • Medicare does cover this add on code.
  • L5845  describe characteristics of a device, and this knee has that function, so it is appropriate to bill for this code.
  • This feature IS medically necessary. The CP needs to articulate why this patient would benefit clinically from adjustable stance flexion, and that the key benefits relate to safety/stability

 

More information about the defunct audit issue may be found in this R&R post


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