Insurance Committee Report

How to Navigate Medicare DME Same & Similars

There has been a policy with the DME MACs that has been present that is now being enforced.  The summary of this policy is that patients can only get 1 AFO type device per limb every 5 years.  The 5 years includes devices dispensed at another facility or by another doctor. This is enforced for the following AFO codes:

L1900, L 1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L 2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631.

The policy includes both custom and prefabricated AFOs.  The policy leaves for exceptions to this rule including a lost/stolen device, one that is irreparably damaged, or if there is a new diagnosis resulting in the need for a new, different type of device.

Providers can look up the patient’s AFO status through Medicare’s Provider Portal available on the DME MAC Homepage.   At my office, we do this prior to every Medicare dispense. I recommend utilizing an ABN if you have not checked Medicare’s site or if you are unsure of the status of your patient.  For more information on this, attend the IPMA annual scientific conference. Doctor Paul Kesselman will be discussing this topic in depth.

Patrick McEneaney, D.P.M., F.A.C.F.A.S., A.A.P.W.C.A.