L5645 denials from Empire BCBS?

L5645 denials from Empire BCBS?

William Lifford

5/7/2018

Hello colleagues,

Over the last ten months or so we have found that, as far as Empire BCBS
and Empire Medicare Advantage goes, that L5645 is under attack -- their
position is that if the amputee has a gel liner, that a flexible inner
socket/rigid frame design is duplicative in function.

Basically they assert that just a prosthetic sock is sufficient as an
interface if L5645 (flexible inner socket) is to be used, and if L5673 (gel
liners) is used, then the flexible inner socket is unnecessary.

I have been over every inch of the LCD and Empire's Clinical UM Guideline,
and neither of them say anything about L5645 not being able to be used as
part of the same prosthesis that includes L5673.

I have appealed these L5645 denials numerous times, and have both won and
lost essentially identical cases at the First-Level Appeal stage, at the
Maximus Reconsideration stage, and at the ALJ stage. I just don't get it.
Sometimes we win, sometimes we lose, at any given stage, and it seems like
there is no actual policy or line of reasoning that Empire can give as to
why these codes are being denied. This is even when the physician
provides rock-solid notes that explain what the gel liner will do for the
patient, what the flexible inner socket will do for the patient, and why
these items do not serve the exact same purpose and are not duplicative in
function.


*Which brings me to my questions:*

1. Have any of you been experiencing this same problem?

2. I have heard from some folks in the field *(but I have been unable to
confirm)* that Empire and a number of other insurers use Performant
Recovery (yes, that Performant Recovery) as a prosthetics consultant to
do prosthetic authorizations review. Do any of you have knowledge of or
proof of this?

3. I have also heard from some folks in the field *(but I also have been
unable to confirm) *that the primary architect of the Draft LCD works for
Performant Recovery and that essentially, this person is using Draft LCD
criteria -- because the infamous Draft LCD actually does specify that the
gel liners and flexible inner sockets are basically duplicative in function
-- to judge the medical necessity of prosthetic preauthorizations. This is
happening even though the Draft LCD is not in force and they are supposed
to used the existing, in-force LCD as coverage criteria, presumably because
the claims reviewer crafted the Draft LCD and believes in it fervently.
Same thing here, do any of you have knowledge of or proof of this?

4. Have any of you had more consistent success in appealing denied L5645
codes with Empire BCBS Medicare Advantage?




Thanks so much for your time and assistance with this! I really appreciate
it. I'd be happy to post a summary of responses.


*William Lifford, CP*
*American Board Certified Prosthetist*
*Progressive O&P, Inc.*
1111 Willis Avenue
Albertson, NY 11784
516-338-8585