Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compressor device, non-segmental home model 
(E0650) pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and knee 
orthosis (L1851) electrical stimulator supplies, 2 lead, per month (A4595) neuromuscular stimulator, electronic 
shock unit (E0745) lumbar-sacral orthosis (L0650) provided March 26, 2020. 
 
You asked the Plan to pay for the pneumatic compression devices, orthoses and electronic shock unit and 
supplies. You say that the records provided should support the necessity of the services in dispute. The Plan 
denied your request. The Plan says this service is not covered. The records do not support the billed service. 
Item exceeds the DME reasonable useful lifetime. 
 
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 pneumatic compression devices and the 
orthotics. Our reviewer says that the pneumatic compressor device and knee orthosis are not medically 
necessary for this enrollee in this case. Our physician reviewer found the enrollee described back, bilateral 
hand/wrist, and bilateral knee pain. She had tried medications only. Physical examination was not performed. 
The plan included a back brace, knee braces, and hand/wrist braces. A request for a pneumatic compressor 
device, non-segmental home model (E0650) and knee orthosis (L1851) was requested. Based on the provided 
documentation, this patient had not yet tried physical therapy and has not objective evidence of instability of 
the knees to justify knee bracing. Also, there was no objective evidence of the patient having lymphedema or 
chronic venous insufficiency with venous stasis ulcers to justify a pneumatic compressor device. Therefore, 
this patient does not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that DMEPOS is covered only 
when there are both a physician order and proof of delivery. Medicare rules say that items and services that are 
not medically necessary are not covered. 
 
In this case, the records also show that the enrollee had previously received a lumbar-sacral orthosis from a 
different provider on October 25, 2019. There is no evidence that this orthosis was lost, stolen, or destroyed, 
therefore, coverage is not allowed for replacement of the orthosis. The documentation submitted did not 
include an itemized shipping billing invoice to indicate the specific supplies or proof of delivery for A4595. 
Records show that the plan made multiple attempts to obtain the needed records without success. The records 
show that E0745 and E0651 were billed with either invalid or  incorrect modifiers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Medicare rules for coverage has not been met and the Plan does not have to pay for pneumatic compressor 
device, non-segmental home model (E0650) pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651) and knee orthosis (L1851) electrical stimulator supplies, 2 lead, per month (A4595) 
neuromuscular stimulator, electronic shock unit (E0745) lumbar-sacral orthosis (L0650) provided March 26, 
2020.