Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on
September 28, 2020.
You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the
orthoses are medically necessary. The Plan denied your request. The Plan says there is no history of an office
visit conducted to show the ordering provider could have diagnosed or treated the member for any issues
requiring the orthoses.
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 knee orthosis (L1833LT) and suspension
sleeve (L2397LT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer
found the local coverage determination indicates that the knee orthosis is covered if the beneficiary has had
recent injury to or a surgical procedure on the knee(s). In addition, the rules also state that knee orthosis is also
covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10
Codes that Support Medical Necessity Group 4 Codes section. Knee instability must be documented by
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability,
anterior/posterior Drawer test). Claims will be denied as not reasonable and necessary when the beneficiary
does not meet the above criteria for coverage.
Furthermore, SSA Section 1834(a)(17) states that:
A supplier of a covered item under this subsection may not contact an individual enrolled under this part by
telephone regarding the furnishing of a covered item to the individual unless 1 of the following applies:
(i) The individual has given written permission to the supplier to make contact by telephone regarding the
furnishing of a covered item.
(ii) The supplier has furnished a covered item to the individual and the supplier is contacting the individual
only regarding the furnishing of such covered item.
(iii) If the contact is regarding the furnishing of a covered item other than a covered item already furnished to
the individual, the supplier has furnished at least 1 covered item to the individual during the 15-month period
preceding the date on which the supplier makes such contact.
As a threshold issue, the case file indicates that he received an unsolicited call from the supplier. There is no
evidence that the supplier has previously furnished covered items to the enrollee. Therefore, the elements of
SSA Section 1834(a)(17) preclude coverage of the requested item.
In addition, the enrollee states he has never had a physician-patient relationship with the provider in this case.
The plan has no record of such an encounter. The provided documentation does not provide credible evidence
of a patient -physician encounter required for ordering of durable medical equipment. Therefore, the requested
knee orthosis cannot be recommended. The suspension sleeve can only be approved if the knee orthosis is
approved. Therefore, the suspension sleeve cannot be recommended.
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 knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve
provided on September 28, 2020.