CMS has added Upper Limb Orthoses within the Reasonable Useful Lifetime (RUL) to the proposed RAC issues list for DMEPOS items. This review will be automated.
If approved by CMS, the RAC (Performant Recovery) will review claims for upper limb orthoses with dates of service within 5 years of the date of service of a previously paid upper limb orthoses for the same beneficiary, for HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.
Affected Codes
L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984 and L3995
Applicable Policy References
- Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
- Social Security Act, Section 1834 (a), Payment for Durable Medical Equipment
- Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i),(ii) and (iii)-Payment for Other Items of Durable Medical Equipment
- 42 CFR, Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor, and (c)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
- 42 CFR, Section 405.986-Good Cause for Reopening
- 42 CFR, Section 414.210-General Payment Rules
- CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15-Covered Medical and Other Health Services, Section 110.2.C-Replacement
- CGS Administrators LLC, and Noridian Healthcare Solutions LLC, Local Coverage Article, Standard Documentation Requirements for All Claims Submitted to DME MACs, A55426-Effective 01/01/2017, Revised 08/28/2018