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2019 Quarterly Status Report – HCPCS Code L0450-L0651

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows:

An analysis of the claim denials showed that the top reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. Refer to L33790 and A52500 43.33%
2 The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. Refer to L33790 and A52500 30.00%
3 Medical records do not support one of the four criteria for a spinal orthosis. Refer to L33790 20.00%
4 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 16.67%
4 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04 16.67%
6 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4 13.33%
7 The detailed written order is missing a description of the item. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 6.67%
8 The documentation submitted is incomplete 3.33%
8 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8 3.33%
8 The physicians order, Certificate of Medical Necessity, supplier prepared statement, or the physicians attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 5.7 3.33%
8 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual 3.33%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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