Same or Similar Rule with Respect to Ankle Foot Orthoses

How is one able to determine whether the Same or Similar Rule with respect to Ankle Foot Orthoses applies and how should it be addressed?

Prior to providing a new item, and to gain the necessary information required (has there been a change in beneficiary's medical condition that supports need for a different type of similar item or if it has been lost, stolen, or irreparably damaged) to determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained or not, it is best to:

Verify that a beneficiary has/has not had a same or similar item.

• - If he/she has not, bill claim without ABN (no ABN is necessary)
• - If he/she has, determine if item has reached its specific reasonable useful lifetime (RUL). For AFOs, it is 5 years.
  •                - If it has, bill claim without ABN (no ABN is necessary)
  •                - If it has not, obtain an ABN and bill claim with applicable modifier.
• - Verification options include:

               1. Ask beneficiary

               2. Check via CGS Administrators, LLC and/or Noridian Medicare Interactive Voice Response (IVR)

               3. Access such information within CGS Administrators LLC and/or Noridian Medicare Portal

Same or Similar Chart

• - The list is NOT all inclusive and that while every effort is made to keep it current, there may be relationships that might trigger a denial that are not listed.

L1900, L1902, 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, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631

This is my opinion.

Michael G. Warshaw

DPM, CPC

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