LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-03 Widespread Prepayment Probe for HCPCS Codes L0631 and L0637

March 22, 2013

  • Widespread Prepayment Probe for HCPCS Codes L0631 and L0637 (Lumbar-Sacral Orthoses)

DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS codes:

L0631 (LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT)

L0637 (LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT)

This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.

Per the Local Coverage Determination (LCD) for Spinal Orthoses: TLSO and LSO (L11470):

HCPCS Code L0631and L0637 is covered when it is ordered for one of the following indications:

To reduce pain by restricting mobility of the trunk; or
To facilitate healing following an injury to the spine or related soft tissues; or
To facilitate healing following a surgical procedure on the spine or related soft tissue; or
To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.
Suppliers will be sent a documentation request for information listed below. The requested documentation must be returned within 45 days from the date of the letter to avoid claim denials.

Documentation should include the following items:

Physician order for the item. Include both the dispensing order (if applicable) and the detailed written order which include the following elements:
Description of the item
Beneficiary’s name
Prescribing Physician’s name
Date of the order and the start date, if the start date is different from the date of the order
Physician signature (if a written order) or supplier signature (if verbal order)
Information from the medical record that demonstrates the reasonable and necessary coverage criteria for the item(s) are met.
Proof of delivery with name, address and signature of the beneficiary or designee; the item(s) provided; date of delivery; and supplier identification.
Invoice(s) for the item(s) provided including manufacturer name and model number.
Any other pertinent information that would justify payment for the item(s) provided.
Advanced Beneficiary Notice (ABN) if one was obtained, this must be submitted with the above requested documentation.
To avoid unnecessary denials for missing or incomplete information, please ensure when submitting documentation requests that all requested information is included with your file and respond in a timely manner.

It is important for suppliers to be familiar with the coverage criteria and documentation requirements as outlined in the LCD and Policy Article. Suppliers can review the LCD for Spinal Orthoses: TLSO and LSO (L11470) and the related Policy Article (A23663) on the NHIC Web site at: http://www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml