Wiki aranesp denials

[rross]

I realize this issue has been addressed many times before, but I would like some help.

I realize If a patient is receiving iron for iron def and aranesp, the aranesp will not be covered by medicare for any reason. However we are getting repeat denials on a patient who according to her notes is receiving aranesp for MDS and in listed in the active problems is iron def. improved. Am I correct in assuming the claim is being denied due to the iron def, even though it is improved? I once thought it would not be covered if given the same day as iron, but that does not seem to be the case.

The patient states she will refuse to have the treatment if medicare won't pay. Would hate to see a patient trade her health due to financial concerns

Any guidance would be greatly appreciated.

 

[cmcgarry]

Who is your Medicare carrier? I suggest checking out their LCD if they have one. Ours (Noridian) is very specific about tx w/Aranesp or ProCrit, that ESA treatment is excluded where there is a current anemia resulting from iron, folate, and/or B-12 deficiency - they are quoting the NCD here. ICD9 codes 281.0 - 281.9 should not appear on a claim for a patient receivig ESA therapy when these conditions do not underlie and/or are not responsible for the current anemia. So, if the iron deficiency anemia is the reason for the treatment, Medicare will not cover it. Only if the iron deficieny is resolved, or is the result of the ESA therapy (code V58.69) would it be covered.
Again, go through the NCD and your LCD if there is one very, very carefully. Request assistance from the provider concerning if this was underlying iron deficiency or was the iron deficiency caused by the ESA therapy.
I hope this helps somewhat.