Wiki Walking boot for ankle sprain denied as "routine"?

[JMichelle]

Hello,

We gave a patient a Walking Boot with the sprained ankle diagnosis and UHC is denying this as "not covered when considered routine".
I am attempting to appeal this but I'm not sure why this would be even considered routine on their part?
Has anyone had experience with this?

Thank you !

 

[iowagirl77]

I haven't seen that denial for a boot before, but I have a few questions to maybe narrow the issue down:
-What HCPCS did you bill?
-Was it billed with home as POS?
-Was there any service other than the E/M billed?
-Have you reviewed their DME policy?
https://www.uhcprovider.com/content...ics-Prosthetics-Multiple-Frequency-Policy.pdf

 

[TPeniston61]

Check the Active LCDs on the cms website. You have to add the KX modifier, which indicates medical necessity.