12/07/2018

DME Denials from Medicare for Patients Who Received DME Items/Devices on the Same Extremity Within the Last 5 Years

We are getting DME coding denials for Medicare for patients who received DME on the same extremity within the last 5 years (even if the codes are different). Example1: We billed L1902-KX-LT for a patient with DOS 09-17-2018 (with Dx M76.72, R26.2) which was denied because the same patient was billed L1902-KX-LT for DOS 03-26-2015 (with Dx 727.06, 729.5). Example2: We billed L1902-KX-LT for a patient with DOS 08-27-2018 (with Dx M76.72, R26.2) which was denied because the same patient was billed L1902-KX-LT for DOS 01-19-2017 (with Dx M76.72, R26.2). Example3: We billed L1970-KX-LT, L2820-KX-LT for a patient with DOS 07-30-2018 (with Dx M76.822, M25.572, M24.272, R26.2) which was denied because the same patient was billed L1906-KX-LT for DOS 09-25-2017 (with Dx M76.822, S93.422A, S93.492A, R26.2). DME Codes L1902 and L1906 are not considered permanent devices and may even have been dispensed for different reasons. Is it unreasonable to find that the lifespan of these DME devices should be greater than 6 months? What would be an appropriate response for an appeal?

Since the LCD policy from Noridian Medicare services expects the lifespan of the item to be five years, the only way to appeal the decision, is to have the AFO re-processed is to file a redetermination with Medicare. In order to have sufficient documentation for the appeal, the following documentation should be included:

• A letter outlining the medical necessity for why the patient needs a replacement device within the five year period
• All supporting documentation from the patient’s chart
• Any photographs that show the old equipment being substandard to address the patient’s needs, if necessary

If any patient requests a new or updated AFO within 5 years and there is not sufficient documentation, an ABN should be signed since Medicare will only cover one item every 5 years.