L9900 Medicare coverage

Local coverage indication

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Excerpt from LCD L33318 version 63, effective 01/25/2026. CMS LCD L33318.

Local coverage indication

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Excerpt from LCD L33737 version 20, effective 01/01/2020. CMS LCD L33737.

From A52465

For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), the medical records must include documentation of the beneficiary’s physical examination of the affected knee(s), including all of the following: The joint laxity test(s) performed; and, A description of the exam findings that support objective joint laxity. For a knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1844, L1845, L1846, L1851, L1852) for the management of an ambulatory beneficiary with knee instability, the medical records must include documentation of all of the following: The beneficiary’s ambulatory status; and, A physical examination of the affected knee(s), including all of the following: The joint laxity test(s) performed; and, A description of the exam findings that support objective joint laxity.

CMS source A52465

From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs

GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific

CMS article A55426

From A52462

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS. Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner. When billing for an item or service at a greater frequency than that described in the policy, there must be documentation in the beneficiary’s medical records that corroborates the order and supports the medical necessity of the items and quantities billed. This information must be available upon request. The treating practitioner's records must contain information which supports the medical necessity of the item ordered.

CMS source A52462

From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs

GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific

CMS article A55426