Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves,the lumbar-sacral orthosis, and the shoulder-elbow-wrist-hand orthosis provided on February 6, 2020.You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397), the lumbar-sacral orthosis (L0650), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses are medically necessary The Plan denied your request. The Plan says the orthoses are not medically necessary. 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 orthoses (L1851) and suspension sleeves (L2397) thelumbar-sacral orthosis (L0650), and the shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the enrollee's chief complaints were lower back pain, right knee pain, and right anterior shoulder pain, 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 an LSO 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 orthoses with sleeves 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, either of the enrollee's knees, 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 shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. 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 a credible physical examination of the shoulder.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 orthoses (L1851) and suspension sleeves (L2397),the lumbar-sacral orthosis (L0650), and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, the lumbar-sacral orthosis, or the shoulder-elbow-wrist-hand orthosis provided on February 6, 2020.