# Humana and GY modifier



## aceubanks (Mar 25, 2019)

We have a few DME items we dispense that are non-covered by Medicare.  I submit the charge to Humana in the same exact format as what I submit to Medicare.  However, Humana continually denies them stating that I am coding them incorrectly.  Because of the way they deny it (CO4), I am not allowed to bill the patient.  

This is what I submit:

L3100  RT or LT, GY     POS 12
L3260  RT or LT, GY     POS 12
L3000  RT, LT, GY        POS 12  (billed on individual lines)

The diagnosis codes are always consistent with LT or RT.  

In the case of L3260, they even told me, in writing, that I needed to code it as a Diabetic Shoe because the patient was a diabetic, and no matter how much I explained and gave them documentation on it, they did not understand that they were asking me to commit fraud by billing something we did not dispense.   

I have appealed these and requested them to correct their denial to PR96, which is what Medicare uses. I've provided the Medicare LCD and highlighted that it is statutorily excluded. I have given them copies of the L3260 brochures that detail exactly what it is, what its used for and the recommended code from the manufacturer.  I have even sent them them copies of Medicare remits showing them how they deny it (HIPAAtized of course!).  

I have tried all kinds of billing scenarios:  no modifiers, GY only, RT or LT only, putting the GY first, putting RT or LT first.  Nothing works.

Has anyone else had this issue with the GY modifier and Humana or how are you billing and getting reimbursed or proper denial?


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## mbcool (Sep 17, 2020)

We bill them out the same way you do. first they request a medical record pre-pay review. Then they deny again and when we call them, they say the review was completed with no findings so we have to work with claims. We then remove the RT and LT mods and resubmit. Then they deny it as the procedure code is inconsistent with the modifier used or a required modifier is missing. The one and only time we get the L3000 code paid by Humana is if the patient is diabetic, then we can use A5513 for the custom orthotics. We have been struggling with Humana over these for more than 2 years. Some places use the KX, which would only be correct if the patient has a special leg brace with a special shoe, per the CMS policy. I wish someone at Humana would tell us what the problem is and getting an ABN is like pulling teeth for the staff. lol. Any help would be appreciated.


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