Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated postoperative hip abduction type hip orthosis 
and hip joint addition to lower extremity provided on August 11, 2023. 
 
You asked the Plan to pay for the prefabricated postoperative hip abduction type hip orthosis and hip joint 
addition to lower extremity. You say that the prefabricated postoperative hip abduction type hip orthosis and 
hip joint addition to lower extremity is medically necessary. The Plan denied your request. The Plan says there 
is no evidence to support that this hip brace is reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  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 prefabricated postoperative hip 
abduction type hip orthosis and hip joint addition to lower extremity. Our reviewer says that the requested 
prefabricated postoperative hip abduction type hip orthosis and hip joint addition to lower extremity are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was 
being treated for right hip arthritis. Past orthopedic surgical history was positive for a right total knee 
replacement. The enrollee presented with right knee pain that is chronic, with weakness present for the past 
four months. The enrollee has had multiple falls and is using a walker to help ambulate. The enrollee has tried 
exercising her knee, but her back started to bother her. The enrollee presented with her right lower extremity 
giving out, which she believes may be her knee, although she does have a history of fairly advanced 
degenerative spine disease. The exam reveals lower back tenderness. Three is a painless range of motion of the 
right hip. The right knee reveals a well-healed keloid incision. The range of motion is 0-95. There is minimal 
tenderness medially but no instability. X-rays of the pelvis and right knee show a well-placed total knee 
without evidence of any loosening. However, detailed documentation is not evident regarding this enrollee 
having undergone or planning to undergo any right hip surgical procedures. Additionally, the provided exam 
from July 6, 2023 did not corroborate hip pathology including subjective and objective findings that would 
require the use of bracing. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested prefabricated post-
operative hip abduction type hip orthosis and hip joint addition to the lower extremity is not medically 
reasonable or necessary. 
 
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 prefabricated postoperative hip abduction type hip orthosis and hip joint 
addition to lower extremity have not been met. Therefore, we decided that the Plan does not have to pay for a 
prefabricated postoperative hip abduction type hip orthosis and hip joint addition to lower extremity provided 
on August 11, 2023.