The response provided by Dr. Freedman is very thorough and quite accurate.Most third party payers adapt Medicare Fee For Service policiesbecause they do not want to cover the costs of developing their own policies which have already been vetted by the medical directors for the four DME MAC.
Most third party payers cover themsevles by burying somewhere in their policy documents the following type of statement: Unless otherwise noted , please refer to Medicare reimbursement policy guidelines for coverage information.
These types of statements DO NOT necessarily have to be stated in the specific DME (or medical/surgical) policy. They may often be found in the operational guidelines of the carrier. This can be frustrating and may be difficult to find.
Because of the generality of the statement, you may only see different coverage for (in this case BC) if that exists. Otherwise in the absence of any statements indicating coverage, one should assusme the carrier’s coverage is reverting to the DME MAC policy.
Since the four DME MAC all share the same exact policies, it is rather easy to figure out the coverage policy of payers other than FFS Medicare.
My suggestion would be in the future for all DME related matters on non Medicare carriers, to assume they follow the DME MAC rules, unless you can find otherwise. The only sure fire way unfortunately is to call their customer service line. You may be wise to call twice to affirm you are getting the same answer.And of course preserve the name time of the rep. their employee ID and log ID of the call.
It is my experience that Achilles Tendonitis is not a covered reason, I believe they follow CMS guidelines on this one. It would be plantar fasciitis M72.2 or Contracture diagnoses. The following is from the DMERC Noridian which I feel would be applicable even though BCBS Carefirst did not have this posted on their site.
An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met:Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and, Reasonable expectation of the ability to correct the contracture; and, Contracture is interfering or expected to interfere significantly with the beneficiary’s functional abilities; and, Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses).If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).Covered Diagnoses:M24.571 Contracture, right ankleM24.572 Contracture, left ankleM24.574 Contracture, right footM24.575 Contracture, left footM72.2 Plantar fascial fibromatosis
Question: I received 2 denials this week from my BCBS, it was about using my diagnosis Achilles Tendinitis with my L4397, why? What is your advice when I appeal this?
The response provided by Dr. Freedman is very thorough and quite accurate.Most third party payers adapt Medicare Fee For Service policiesbecause they do not want to cover the costs of developing their own policies which have already been vetted by the medical directors for the four DME MAC.
Most third party payers cover themsevles by burying somewhere in their policy documents the following type of statement: Unless otherwise noted , please refer to Medicare reimbursement policy guidelines for coverage information.
These types of statements DO NOT necessarily have to be stated in the specific DME (or medical/surgical) policy. They may often be found in the operational guidelines of the carrier. This can be frustrating and may be difficult to find.
Because of the generality of the statement, you may only see different coverage for (in this case BC) if that exists. Otherwise in the absence of any statements indicating coverage, one should assusme the carrier’s coverage is reverting to the DME MAC policy.
Since the four DME MAC all share the same exact policies, it is rather easy to figure out the coverage policy of payers other than FFS Medicare.
My suggestion would be in the future for all DME related matters on non Medicare carriers, to assume they follow the DME MAC rules, unless you can find otherwise. The only sure fire way unfortunately is to call their customer service line. You may be wise to call twice to affirm you are getting the same answer. And of course preserve the name time of the rep. their employee ID and log ID of the call.
It is my experience that Achilles Tendonitis is not a covered reason, I believe they follow CMS guidelines on this one. It would be plantar fasciitis M72.2 or Contracture diagnoses. The following is from the DMERC Noridian which I feel would be applicable even though BCBS Carefirst did not have this posted on their site.
An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met:Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and, Reasonable expectation of the ability to correct the contracture; and, Contracture is interfering or expected to interfere significantly with the beneficiary’s functional abilities; and, Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses).If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home). Covered Diagnoses: M24.571 Contracture, right ankle M24.572 Contracture, left ankle M24.574 Contracture, right foot M24.575 Contracture, left foot M72.2 Plantar fascial fibromatosis
Question: I received 2 denials this week from my BCBS, it was about using my diagnosis Achilles Tendinitis with my L4397, why? What is your advice when I appeal this?