Medicare Same or Similar General Information
- Medicare will only pay for one item within a 5-year period to treat a patient’s condition, unless Medicare policy specifies a timeframe of less than 5 years
- Medicare will only cover an additional Same or Similar item within the Reasonable Useful Lifetime (RUL) timeframe if:
- The item is lost
- The item is irreparably damaged
- The patient’s medical condition has changed and the original product will no longer meet the patient’s needs
- Irreparable WEAR is NOT COVERED
- If no ‘Similar’ product grouping is designated for a HCPCS, the HCPCS must be checked for ‘Same’
- If a ‘Similar’ product grouping is specified, the HCPCS code should be checked against all codes within the grouping
- If a Same or Similar HCPCS code is found, patient should be presented with an ABN
- The ABN’s reason of non-coverage should state that the ‘patient has recently received a similar item within the RUL
- This will preserve DJO’s billing rights and will allow DJO to bill the patient for the product should we receive a Same/Similar denial
Knee RUL
Currently, the only DJO products that have a RUL of less than 5 years are knee products Knee RUL is as follows:
- 1 Year: L1810, L1812, L1820, L1830
- 2 Years: L1831, L1832, L1833
- 3 Years: L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860
Supporting Links
Noridian has published a Same and Similar grid that is available on their website.
Noridian Same or Similar grid: https://med.noridianmedicare.com/web/jddme/topics/same-or-similar
CGS does not have a published grid, however they have a tool on their website to look up Same or Similar categories. CGS’s tool largely follows Noridian’s recommendations, but takes it a step further and has grouped Upper Extremity HCPCS codes together; although there are currently no published guidelines grouping UE HCPC codes together as ‘Similar.’
CGS tool: https://www.cgsmedicare.com/medicare_dynamic/jc/samesimilar/samesimilar.aspx
Product categories relative to DJO are:
- AFO/KAFO
- Canes/Crutches
- Knee Orthoses
- Walkers
- Spinal Orthoses
- Traction Frames
**Printable PDF Attached**