Jurisdiction D DME MAC recently completed a widespread prepayment review of certain spinal orthoses, L0631 and L0637, due to an analysis compiled by CERT audit contractors. The results are very troubling and will likely trigger more widespread reviews of the L codes involved. In total, 101 claims for L0631 were reviewed and 96 were denied. An additional 80 claims for L0637 were also reviewed with 80 being denied. The reasoning for the denials is provided in greater detail below, but documentation errors and delivery notices account for a large majority of the denied claims. Below is a section from the report compiled by DME MAC Jurisdiction D (Noridian).
Primary documentation errors that resulted in denial of claims
- 24% of L0631 claims received a denial as Criteria 1 not met.
- 14% of L0637 claims received a denial as Criteria 1 not met.
The beneficiary’s medical records did not indicate the LSO order as reasonable and medically necessary as described in LCD 11459.
A lumbar-sacral orthosis is covered when it is ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
- 23% of L0631 claims received a denial as documentation does not support medical necessity for the item requested.
- 13% of L0637 claims received a denial as documentation does not support medical necessity for the item requested.
The beneficiary’s medical records did not justify the LSO as medically reasonable and necessary.
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
- Beneficiary’s medical record submitted does not have sufficient objective documentation to validate beneficiary use of a LSO as reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member.
- According to the supplier manual the provision of an identical or nearly identical item may be replaced when a new physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. The useful lifetime of a spinal orthosis is no less than 5 years. Medical record documentation must validate the need for a new or replaced spinal orthosis.