Practice Management Alert

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?

Tennessee Subscriber

Answer: Your Medicare carrier is probably determining that the service is "medically unnecessary" from its perspective. One reason could be that the service exceeds frequency limits (believe it or not, you get a medical necessity denial for frequency). The denial could also be because the diagnosis is not one of the diagnoses listed on the local coverage determination (LCD) or national coverage determination (NCD) for that service, or the carrier is following a non-published carrier determination.

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.

Next step: There is a good chance you will not win at the redetermination level because that is the same organization that sets the frequency limits, and you will need to go to the next level, a qualified independent contractor (QIC). If you can make a medical necessity case via the medical documentation, you might have a chance to win.

Check yourself: Similarly, if the claim does not have a diagnosis that is on the LCD list, check the documentation. If you find a diagnosis in the notes that is on the LCD/NCD list of allowed diagnoses, send the claim in for redetermination, with a cover letter and the notes showing that a covered LCD/NCD diagnosis is documented and applies to the encounter, proving medical necessity.

If your physician does not agree with the LCD/NCD and feels that he can fight the LCD/NCD and prove the medical necessity of his service, he can appeal via redetermination and will probably have to go to a 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.

Tip: Other carriers- LCDs/NCDs that support your diagnosis may also help support the medical necessity. Even if you win, this appeal will not change the LCD/NCD. You need to go to the carrier and fight on a case-by-case basis until you get the LCD/NCD changed.

Note: Fighting a denial based on a non-published carrier determination is more difficult, and you will have to go to the QIC level or higher to prove the medical necessity.