Medicare Denials for L4205 and L7520

Medicare Denials for L4205 and L7520

Melissa A. Bolton, Admin. Dept.

2/8/2013

Hi everyone,

Has anyone else had issues with Medicare denying L4205 and L7520 (labor) when
more than 8 units (2 hours) is being billed?

Whenever we bill more than 8 units (2 hours) Medicare denies it as Payer deems
the information submitted does not support this many/frequency of services.

An example of this is we billed L4205 x 25 (6.25 hours) for repairs to a
patients BIAFOS. The cost of the labor and materials was far less than what the
cost of a new set of BIAFOS would have been and BIAFOS were delivered less than
3 years ago. Medicare denied the entire line item. We submitted all medical
documentation to show medical necessity including a breakdown of the labor
billed. The result of the redetermination was that they paid 8 units of L4205
and denied the other 17 units. The reason for the denial was The number of
Days/Units of Service exceeds are acceptable maximum.

I have called Medicare to follow up on this denial and am continually told that
we are exceeding the Maximum number of units based on the Medically Unlikely
Edits List. I have gone through this list multiple times and L4205 and L7520 are
not listed on the MUE List.

So, now I am up to the Reconsideration level and will most likely have to go to
ALJ level in an attempt to get the additional 17 units paid.

Has anyone else had this type of issue and if so, has anyone come up with any
bright ideas or had success in the appeal process?

Thanks!

Melissa Bolton
Funding Assistant
Real Life Prosthetics