Insurance companies limit how often someone can get a new brace. For example, Medicare and most insurance companies limit replacement ankle bracing to 1 brace every 5 years. This is the case, even if the new brace is a completely different design from the first. The only exception to this rule is if there is strong evidence that you experienced a significant anatomical change, or if the first brace broke during an accidental event. An example of an accidental event would be a car accident.
Common Claim Denials
Unfortunately, claim denial for all replacement bracing is the ‘norm’ now. This is now the case even when the two braces serve very different purposes.
An example of this situation might be that:
- Your doctor provides you with a healing boot at your post-surgery appointment
- The boot is not intended for long term use
- Your doctor also prescribes a custom brace for you
- You are to wear the healing boot until your custom brace is made
- Your doctor submits a medical claim for the healing boot. That is considered brace #1.
- Your custom brace will be considered brace #2.
- Medicare will deny the claim for the custom brace because it was provided within 5 years of the healing boot.
We must submit proof of medical necessity during the appeal process. The appeal process can take months to years. Even with strong evidence of necessity due to anatomical change, the denials continue.
Our Efforts to Appeal
At your Bio-Tech appointment we will ask you about your brace history. Please let us know about any bracing you have received, regardless of what type of bracing it was.
If you received any brace of any design for the body part we are treating, we will discuss this with you in detail. Additionally, we will:
- Request your doctor’s notes
- Obtain your Medicare billing history for all bracing with 5 years
- Evaluate your unique situation to figure out if replacement meets Medicare’s criteria for coverage
- Consider asking you to sign an Advance Beneficiary Notice on Non-Coverage (ABN)
If your doctor’s notes do not include enough details to address the need for replacement, we will contact your doctor. You may need to schedule a separate appointment with your doctor to ensure the required notes are completed.
We are also working with national prosthetic organizations and with Medicare directly to address the unreasonable denial of claims when replacement clearly meets criteria.
Actions You Can Take
Some doctors are not aware that temporary bracing solutions, like healing boots, count towards your 5 year bracing allowance. We are educating the medical community about this issue, but you can also educate your medical team. Prescribing professionals should know:
- Notes should specify why any brace is needed
- Replacement bracing is only covered due to significant anatomical and/or physiological changes or irreparable damage due to a specific accident. Gradual damage and wear and tear do not meet criteria.
- We will likely request additional documentation from your doctor to support the need for replacement
You can also contact Medicare directly at 1-800-MEDICARE to voice your concerns.