Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the wrist hand orthosis, the knee
orthosis and suspension sleeve provided on December 9, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the wrist hand orthosis (L3916), the knee
orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan
denied your request. The Plan says there is no evidence of an established relationship between the enrollee and
the ordering physician.
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 the lumbar-sacral orthosis (L0650), the wrist
hand orthosis (L3916), the knee orthosis (L1851) and suspension sleeve (L2397). Our reviewer says that the
orthoses are not medically necessary. Our physician reviewer found the enrollee's chief complaints were lower
back pain, chronic pain knee right, and chronic pain wrist left, documented in 3 separate notes on the same date
of service. The available documentation in the case file does not support that the requested lumbar-sacral
orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria
established by the LCD. A physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar -sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as
there is insufficient documentation of a credible physical examination of the back.
The documentation in the case file does not support that the requested knee orthosis and sleeve were medically
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the
LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, 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.
The documentation in the case file does not support that the requested wrist/hand orthosis was medically
reasonable and necessary for the enrollee in this case. 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 the lumbar-sacral orthosis (L0650), the wrist hand orthosis (L3916), the knee
orthosis (L1851) and suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does
not have to pay for the lumbar-sacral orthosis, the wrist hand orthosis, the knee orthosis and suspension sleeve
provided on December 9, 2019.