Medicare Compliance & Reimbursement

Question: We performed a service that we know was medically necessary, but the carrier denied it. Is redetermination the only way to proceed with trying to get this claim paid, or is there another way to get Medicare to reconsider?

Answer: Your Medicare carrier is probably determining that it is "medically unnecessary" because of one of two reasons, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-OT, CHCC, director of outreach for the American Academy of Professional Coders in Salt Lake City. "One, it exceeds frequency limits (believe it or not, you get a medical necessity denial for frequency), or the diagnosis is not one of the diagnoses listed on the local coverage determination (LCD)," Cobuzzi says.

If your physician exceeded the frequency allowances and the medical record confirms a reason for doing it more often than normally allowed, you can request redetermination with the notes and a cover letter, explaining why this should be allowed more frequently than normally permissible. "There is a good chance you will not win at the redetermination level, as they are the same organization that sets the frequency limits, and you will need to go to the next level, a qualified independent contractor (QIC)," Cobuzzi says. "If you can make a medical necessity case via the medical documentation, you might have a chance to win."

If you do not have a diagnosis that is on the LCD list, check the documentation. "If you find one in the notes that is on the LCD list of allowed diagnoses, send it in for redetermination, with a cover letter and the notes showing that a covered LCD diagnosis is documented and applies to the encounter, proving medical necessity," Cobuzzi says.

If your physician does not agree with the LCD and feels that he can fight the LCD and the medical necessity of his diagnosis, the doctor can appeal via redetermination and probably will have to go to QIC. You will need the notes, a cover letter and whatever you might have from the scientific literature to support your treatment for this medical necessity. "Other carriers' LCDs that support your diagnosis may also help support the medical necessity," Cobuzzi says. "Even if you win, this appeal will not change the LCD. You need to go to the carrier and fight on a case-by-case basis until you get the LCD changed," she suggests.