Corporate
CGS Administrators, LLC

Serving the states of AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV and the U.S. territories Puerto Rico and the Virgin Islands

November 8, 2018

Status Report for Quarter 2 – 2018: HCPCS Code L1832, L1833

A summary report for claims reviewed between April 1, 2018 and June 30, 2018 follows:

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. 62.98%
2 The file does not include medical records that describe a recent injury or a surgical procedure on the knee(s). 28.37%
3 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. 25.96%
4 The medical record does not contain one of the diagnoses required by the LCD. 22.12%
5 The file does not include medical records that support that the beneficiary is ambulatory. 11.54%
6 The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 4.33%
6 The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 4.33%
8 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8 3.85%
9 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04 3.37%
10 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4 2.88%

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

Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved