04/21/2022
Revised-Incorrect Fidelis Denials for AFO and Night Splints-Misinterpretation of their definitions of “Custom-Fitted”
There is an issue we are having with prefabricated AFO braces and Fidelis. Fidelis is denying the code L1971, saying that because there is no custom fitting performed when the item is being dispensed. This code is meant for a prefabricated brace, which isn't meant to be custom fitted. See link below for L1971: https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2021/custom-fitted-orthotic-hcpcs-codes-without-a-corresponding-off-the-shelf-code-correct-coding Basically what's happening is that we are appealing and they are denying, saying that it's not enough of a modification. I'm not sure if it's something that's already been brought up but I think they're miscategorizing this brace. The same issue is happening with a night splint. In addition, we have appropriate documentation within our notes that the brace is appropriately fit. We also have auth prior to dispensing. If anyone else is having this issue, let me know.
As per the DME AFO LCD policy, since the L1971 is classified as PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (emphasis added), documentation must be detailed stating what type of fitting, adjustment, modifcation or customization was done to the actual brace for it to fit and be suitable at time of dispensing for the patient’s foot. Simply stating that the brace is a good fit will not suffice.
The lay definitions from Encoder for the prefabricated AFO (L1971) and the custom AFO (L1970):
Prefabricated: Ankle foot orthotics (AFO) are orthoses or braces made of plastic or other material encompassing the ankle joint and all (or part) of the foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities.
Custom: A custom-fabricated orthosis is one that is individually made for a specific patient starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, and so forth. It involves substantial work, such as cutting, bending, molding, sewing, and so forth. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item. A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis in which an impression of the ankle joint is made by means of a plaster cast, CAD-CAM technology, etc. This impression is then used to make a model of plastic of the ankle joint to be braced. The orthosis is then molded on this model to be fit exactly to the ankle. This provides for free limited motion or assists in dorsiflexion and plantar flexion while limiting inversion and eversion of the ankle. The plastic design is lightweight and allows the patient to interchange shoes. It may provide critical foot and arch support. Neutral arch position promotes healing of injured ligaments. Side supports help position the brace correctly and tightly to move in harmony with the foot and ankle and assure full time protection and support.