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Spinal Orthosis Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for lumbar sacral orthosis (LSO) HCPCS codes L0450-L0651 reviewed July 1 – September 30, 2024. The error rate for this quarter is 42.99%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 29.17%
2. Medical records do not support one of the 4 criteria for a spinal orthosis. 28.33%
3. The HCPCS procedure code on the claim is not correct for the items billed. 24.17%
4. The order is missing a description of the item. 11.67%
5. The documentation does not contain a valid written order prior to delivery. 1.67%
6. We did not receive any medical record documentation. 1.67%
7. The documentation does not contain a valid order. 0.83%
8. The documentation is incomplete. 0.83%
9. The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. 0.83%
10. The documentation shows the beneficiary returned the items. 0.83%

*The total percentage will be greater than 100% because some claims were denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

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Updated: November 1, 2024

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