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Performant Recovery posted one new automated issue to their approved issues list.

Upper Limb Orthoses within the Reasonable Useful Lifetime (RUL)

On May 17, 2019, Performant Recovery, the National DMEPOS RAC, added upper limb orthoses to their approved issues list. Performant will review claims for upper limb orthoses with dates of service within 5 years of the date of service of a previously paid upper limb orthoses for the same beneficiary. HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.

Affected Codes

L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984 and L3995

Applicable Policy References

  • Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
  • Social Security Act, Section 1834 (a), Payment for Durable Medical Equipment
  • Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i),(ii) and (iii)-Payment for Other Items of Durable Medical Equipment
  • 42 CFR, Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor, and (c)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
  • 42 CFR, Section 405.986-Good Cause for Reopening
  • 42 CFR, Section 414.210-General Payment Rules
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15-Covered Medical and Other Health Services, Section 110.2.C-Replacement
  • CGS Administrators LLC, and Noridian Healthcare Solutions LLC, Local Coverage Article, Standard Documentation Requirements for All Claims Submitted to DME MACs, A55426-Effective 01/01/2017, Revised 08/28/2018

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program.

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.

Contact us for more information!