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March 19, 2021

Widespread Post-Pay, Service Specific Review Announcement – HCPCS Codes L5700 and L5701

CGS' Medical Review staff will be conducting a complex post-pay, service specific medical review of HCPCS codes L5700 and L5701 (Lower Limb Prostheses). This review will be conducted because data analysis revealed that Jurisdiction B's allowed dollars for HCPCS codes L5700 and L5701 were significantly above expected amounts. Additionally, the orthotics policy group ranked #1 in total Comprehensive Error Rate Testing (CERT) errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial, but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order)
  2. Detailed written order
  3. Treating physician's records
  4. Prosthetist's records
  5. Medical records that verify the claim for the prosthetic components(s) defined in the lower limb prostheses Local Coverage Determination (LCD) and related Policy Article (PA)
  6. If the beneficiary has or had same/similar items, documentation indicating the reason new equipment/item(s) is medically necessary
  7. Any other pertinent documentation
  8. If there is an Advance Beneficiary Notice (ABN) on file, submit the ABN with other requested documentation


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