Skip navigation

David McGill Blogger

New K3 Foot Results from Region D

Posted by David McGill | January 15, 2015

MAC Region D (Noridian) has published the results from its ongoing prepayment claim review of L5980 claims. As usual, the sample size was small (only 49 claims reviewed):


  • 96% claim denial rate
  • Reasons for denial
    • Documentation doesn’t support the claimed functional level;
    • Documentation doesn’t support the need for replacement of the prosthetic foot;
    • Insufficient evidence that the patient will reach or maintain the selected functional level within a reasonable period of time; and
    • The supplier failed to respond to the additional documentation request.

Since Region D began reviewing L5980 claims, the data has consistently shown claim denial rates of at least 80%.

What does this mean for you?

First, based on these results, Noridian will continue its review of L5980 claims.

Second, though we sound like a broken record on the point, suppliers must comply with the coverage requirements listed in the Local Coverage Determination for Lower Limb Prosthetics. All of the stated reasons for denial in Region D's most recent report are basic requirements listed in the LCD and its accompanying Policy Article.

It's the beginning of 2015. Take the time to go back and review the LCD and Policy Article in detail, even if you are generally familiar with its requirements. Then review a few claims that you have in the pipeline and cross reference what you've compiled against those requirements. Taking the time to do this today may expose gaps in your internal claim process and save you both significant time and money down the road.



Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]