Dharam Mann, MD; Samir Jani, MD; Manjula Singh, MD; Shahzad Hussain, MD
Phone: (732) 202-3000 Fax: (732) 849-0015 gsmedicalcenter.org
Acknowledge receipt & order of Knee Orthosis, HCPCS Code L1833
Knee Brace (L1833)
(initials) acknowledge receipt of Knee Orthosis, HCPCS Code L1833
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf
Instruction: Direction for Knee Brace use: Received:
Yes (initial)
No (initial)
A. Notifier: Garden State Medical Center, 1314 Hooper Avenue, Bldg B, Toms River, NJ 08753 Phone: (732) 202-3000 Fax: (732) 849-0015
Advance Beneficiary Notice of Non-coverage (ABN)
NOTE: If Medicare doesn’t pay for D. brace (durable medical equipment) below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. brace (durable medical equipment) below.
D. Durable Medical Equipment
E. Reason Medicare May Not Pay:
Medicare will pay for one orthotic every five years of a particular type of brace.
Medicare has declared your condition medically unnecessary for this type of orthotic.
Medicare has decided that this orthotic is a noncovered service.
F. Estimated Cost
(Must be included prior to patient signature)
WHAT YOU NEED TO DO NOW:
- Read this notice, so you can make an informed decision about your care.
- Ask us any questions that you may have after you finish reading.
- Choose an option below about whether to receive the D. brace (durable medical equipment) listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131