Reasons for Non-Affirmed Prior Authorization for Knee (L1832, L1833, L1851) and Spinal Orthoses (L0648 and L0650)
Face-to-Face Encounter Issues
The documentation submitted to prior authorization did not include a face-to-face encounter within 6 months prior to the order.
As a condition for payment, 42 CFR 410.38 and Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a beneficiary within the 6 months prior to prescribing items that appear on the Required Face-to-Face Encounter and Written Order Prior to Delivery List
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A qualifying face-to-face encounter is required each time a new order/prescription for one of the specified items on the Required List is ordered.
The face-to-face encounter must support payment for the item(s) ordered/prescribed and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans, or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
For orthoses, the treating practitioner that conducted the face-to-face encounter does not need to be the prescriber for the item; however, the prescriber must:
- Verify that a qualifying face-to-face encounter occurred within the 6 months prior to the date of their prescription; and,
- Have documentation of the qualifying face-to-face encounter that was conducted.
A WOPD must be completed within 6 months after the required face-to-face encounter.
This face-to-face requirement also includes examinations conducted via the CMS-approved use of telehealth examinations, which must meet the requirements of 42 CFR §§ 410.78 and 414.65 for purposes of DMEPOS coverage.
The face-to-face encounter contains a practitioner's signature which does not comply with the signature requirements, and the face-to-face encounter is not authenticated (handwritten or electronic) by the author.
For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies. For example, if the physician's authenticated documentation corroborates the nurse's unsigned note, and the physician was the responsible party per Medicare's payment policy, medical reviewers would consider signature requirements met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable unless the practitioner meets the Rehabilitation Act of 1973.
All signatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Section 3.3.2.4.
Written Order Prior To Delivery (WOPD) Issues
The order was missing or incomplete.
The order submitted with the prior authorization request must include the following:
- Beneficiary's name or Medicare Beneficiary Identifier (MBI)
- Order date
- General description of the item
- The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
- For equipment – In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately).
- Treating practitioner's name or NPI
- Treating practitioner's signature
Medical Record Issues
The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee.
A knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 codes in the Local Coverage Determination (LCD)-related Policy Article.
Additional information is available in the Knee Orthoses Local Coverage Determination (LCD).
The medical record documentation does not demonstrate an objective description of joint laxity for knee instability.
Knee orthoses L1832, L1833, L1843, L1845, L1851, and L1852 are covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the Policy Article. Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).
Additional information is available in the Knee Orthoses LCD.
The documentation indicates the item is needed for post-operative recovery, this item is expected to be included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.
DME MACs do not process claims for DMEPOS items that are subject to consolidated billing or bundled payment under PPS or in a DRG.
Refer to the Claims Processing Manual 100-04 Chapter 1, Section 10.1.5.1.
The medical record documentation indicates the item is needed during post-operative recovery; however, the surgery has not yet taken place.
Prior authorization requests should not be requested prior to the start of medical necessity (before the surgery).
Refer to the Medicare Benefit Policy Manual Chapter 15, Section 110.1, Section C for additional information.
Claims history indicates same or similar equipment within the reasonable useful lifetime.
Prior to submitting a prior authorization request, check for same/similar items through myCGS.
If there is same/similar equipment during the reasonable useful lifetime, suppliers should confirm there is documentation of a change in medical need or that the previous item was lost or irreparably damaged. Irreparable damage may be due to a specific accident or to a natural disaster (such as a fire or flood).
Refer to the Replacement Orthosis During Reasonable Useful Lifetime Documentation Checklist
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Updated: 11.14.23
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