05/14/2021

Proper Documentation for Replacing a Lost AFO

A Medicare patient lost their AFO ( a pair of balance braces) during a hospital stay. They were dispensed just over a year ago. What documentation would be needed to get a replacement pair for the exact same item covered by Medicare during the same/similar 5 year period?

If a patient lost an AFO and requires a replacement device, the provider must have supporting documentation to justify medical necessity, Given the circumstances for the replacement item, it is extremely important to document the personal circumstances for the patient to substantiate the need for a new item to be covered by Medicare,. it is unlikely that Medicare/DME will reimburse the replacement AFO since it was within five years since it was last dispensed on the initial claim submission. A redetermination will need to be sent once the denial is issued to not only substantiate medical necessity, but to also reiterate the patient specific circumstances as an exception  While it is not required, it is recommended that the patient sign an ABN with the expectation that the replacement AFO may be denied as non-covered item due to the frequency guidelines  If the patient has a secondary insurance, they may cover the balance denied by Medicare since they do not have the same frequency guidelines as Medicare in the event that the redetermination does not overturn the denial from Medicare.

The following modifier should be used for repair or replacement of a brace:

RA-The RA modifier is described as replacement of a DME item, due to loss, irreparable damage, or when the item has been stolen.