Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) with suspension sleeve (L2397), ankle-foot braces (L1971), heel cups (L3170), a wrist-hand brace (L3916), and a shoulder brace (L3960) provided on July 16, 2020.

You asked the Plan to pay for a knee orthosis with suspension sleeve, ankle-foot braces, heel cups, a shoulder brace, and a wrist-hand brace. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for payment have not been met because the record does not contain documentation of an established relationship between the enrollee and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis with suspension sleeve, ankle-foot braces, heel cups, a shoulder brace, and a wrist-hand brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaints are of ankle pain, knee pain, wrist pain, and shoulder pain. The documentation in the case file does not support that the requested items were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. With regard to the requested knee orthosis and sleeve, there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. With regard to the requested ankle-foot orthoses, a physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle-foot orthoses were medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankles and feet. With regard to the requested heel cups, the documentation in the case file does not support that the requested heel cups were medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the feet. With regard to the requested shoulder-arm orthosis, a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. With regard to the requested wrist-hand orthosis, an appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist-hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist-hand orthosis was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrist.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis with suspension sleeve, ankle-foot braces, heel cups, a shoulder brace, and a wrist-hand brace have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851) with suspension sleeve (L2397), ankle-foot braces (L1971), heel cups (L3170), a wrist-hand brace (L3916), and a shoulder brace (L3960) provided on July 16, 2020.