Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis, and suspension sleeve provided on August 5, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthosis (L1851), and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses was not met.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 knee orthosis (L1851), and suspension sleeve (L2397). Our physician reviewer found the enrollee was reporting low back pain and bilateral knee pain.  
A telehealth consultation note dated August 2, 2019 signed by the ordering provider does not include a detailed history and physical. This appeal considers the medical necessity for a lumbar-sacral orthosis and knee orthosis with a suspension sleeve. Submitted documentation and Local Coverage Determinations (LCD): Spinal Orthoses: TLSO and LSO (L33790) and Knee Orthoses (L33318).  were considered.  Additionally, requirement for DME found a 42 CFR 410.38 (g) were reviewed.  These guidelines state the following: (A) The physician must document and communicate to the DME supplier that the physician or a physician assistant, a nurse practitioner, or a clinical nurse specialist has had a face-to-face encounter with the beneficiary on the date of the written order up to 6 months before the date of the written order.(B) During the face-to-face encounter the physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist must conduct a needs assessment, evaluate, and/or treat the beneficiary for the medical condition that supports the need for each covered item of DME ordered.(C) The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans or other information as it may be appropriate). Physician must sign or cosign the pertinent portion of the medical record indicating the occurrence of a face-to-face encounter for the beneficiary for the date of the face-to-face encounter when performed by a physician assistant, a nurse practitioner, or a clinical nurse specialist. For purposes of this paragraph (g), a face-to-face encounter does not include DME items and services furnished from an "incident to" service. The submitted documentation does not support a face to face encounter, detailed history or physical examination to support the referenced criteria for the lumbar-sacral orthosis. Without the supporting documentation, medical necessity is not determined.  Medicare guidelines are not met. The denial is upheld The submitted documentation does not support a face to face encounter and physical examination of knee instability. Without the supporting documentation, medical necessity is not determined.  Medicare guidelines are not met. The denial is upheld. Additionally, the suspension is also denied as it is used in conjunction with the denied knee orthosis.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 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 knee orthosis, and suspension sleeve provided  on August 5, 2019