Oncology & Hematology Coding Alert

Question: Does Medicare restrict coverage to only the diagnoses listed under the code’s Local Coverage Determination (LCD)? If so, can we appeal and argue medical necessity with a non-covered diagnosis?

Nevada Subscriber

Answer: If you know you are submitting a claim with a diagnosis code that is not covered based on the CPT^® code’s LCD, you have a few options. First, you should have the patient sign an advanced beneficiary notice (ABN), or other insurance required payment waiver for noncoverage when it is not a Medicare patient, when performing this procedure with a diagnosis not covered under the LCD. This way, should you not be successful in getting Medicare or the other third-party insurance to pay for the procedure, you can bill the patient for the service. When the ABN is signed, you should submit the service with modifier GA (Waiver of liability statement issued as required by payer policy, individual case), which tells your Medicare carrier you have a properly executed ABN on file.

If you submit the claim electronically, you should expect to receive a denial due to medical necessity. Your next step is to resubmit the claim with additional information as an appeal to the denial with more information. In doing so, you’ll want to take all the appropriate measures to ensure your Medicare Administrative Contractor (MAC) understands why the diagnosis supports that the procedure or service was medically relevant and necessary. This includes a surgical note, a written explanation from the physician, and even peer-reviewed data backing up your claims. Consider looking to your specialty society webpage for any relevant information.