Responses to [OANDP-L] FYI NY Sate Insurance - United Healthcare

Responses to [OANDP-L] FYI NY Sate Insurance - United Healthcare

Marty Mandelbaum

6/25/2013

Original Message-----
From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
Behalf Of Marty
Sent: Tuesday, June 25, 2013 12:53 PM
To: <Email Address Redacted>
Subject: [OANDP-L] FYI NY Sate Insurance - United Healthcare

> We have a denial on a replacement socket for transtibial (who's
original prosthesis was paid as a K3 level), UH is stating that because
he is diabetic they consider him a K2. This guy has returned to work as
a car salesman, he drives with his prosthesis, walks on uneven terrain
to show cars on his lot & gets in and out of cars all day.
> They say they follow Mcare guidelines my questions are: Does Mcare
uses K levels in determining socket replacements? Since when does Mcare
determine that a diabetic is automatically a is automatically a K2?

> Thanks
> Marty Mandelbaum CPO

Responses: Thank you all for your responses! Please no more responses!

1 -I think this patient should go to the national diabetic organizations
and a law firm and file a class action suit against United Healthcare. I
would think their actions are not just prejudicial, they would be viewed
by a jury as discriminatory. Labeling every/any diabetic patient as only
capable of being K2 is ridiculous. Another approach would be to call the
consumer affairs or medical reporter for one of the NYC papers or TV
stations. I am sure they would love to be the first to report that a
leading health insurance company has labeled amputees (who are diabetic)
as not capable of being physically active.

2 - Wow. This is good. All diabetics automatically K2s!!!!? That seems
to be the secret agenda. Make all Mcare recipients K2....then start
denying all feet but sach...oh, & no gel liners or flexible inner sockets.
No need for comfort.
Gov't officials & their families need to be provided the same care as
Mcare pts.
Rick Disgruntled CPO in PA

3- I don't have an answer regarding Medicare guidelines in this instance,
but we have had a great deal of success in reversing UHC denials by having
the prescribing MD request a peer to peer review with the reviewing MD.
This direct 'Dr. to Dr.' communication tends to bypass the
other bureaucratic hassles.

4- I would ask for them to provide the specific literature showing that a
diabetic cannot be a K3. Word it nicely, but state to either pay the claim
or provide the written policy where this stated. If THEY are claiming to
follow MCare policy, then they need to prove that they are. They can't just
make stuff up and you have every right to nicely explain that they can't
just make stuff up! In reality, however, they actually can. They follow
Medicare's basic policies, but can change anything they desire. If they
have a written policy that actually states that, you lose. And that's
pretty unlikely.
I am QUITE familiar with ALL O&P related Mcare policy and there is no
mention of diabetes being directly related to Klevel. When you send in your
letter, send a link or a copy of the actual Medicare prosthetic policy and
the LCD and then explain that their medical justification for denial is NOT
in either one. If you send the literature or the link, it will solidify
that you know what you're talking about & have done your homework. If you
demand to see this in writing and they cannot produce it, they may simply
pay your claim. That's how I would handle it. And I have a 100% record of
getting my claims paid. Always be nice and polite in your letters. That's
key.

5- I have had 4 denials from UHC because of medical history vs. K levels.
 One denial was the patient's first initial leg, basic cost, etc. I
appealed all four with documentation and a statement written by the patient
explaining their daily activities. I have won 3 appeals out of 4 and am in
the middle of the 4th. Appeal it. Medicare was here in our practice also
and said if private insurance companies tell you that they follow medicare
guidelines, they usually do not and that is not true

6 -Following the LCD and Policy Articles for Lower Extremity Prosthetics,
the functional K Levels are only used determine which prosthetic feet and
knee systems are appropriate for each beneficiary.
Sockets and liners are not subject to K levels.
IMHO, 1) this MUST be appealed…use the LCD and PA and quote them
specifically to show where UH is incorrect…and 2) the patient MUST file a
complaint with CMS on UH for denying them benefits that Medicare would
allow. The complaint information and forms can be found at CMS.GOV under
the Medicare tab.

7 - I had a patient, last year for an AK socket replacement. UHC originally
denied because of the K level. I tried explaining that for a socket
replacement the only K level requirement should be the amputee meets a K1
level. The replacement was because of a surgical revision.
The patient had presented back as a K2 with using crutches, but still had a
potential to return to a K3 level after the socket replacement. However,
UHC denied because I documented she came in as a K2 at the time, with
potential for K3, when the prescribing MD wrote K3 on his notes; thus
denied because of the discrepancy.
We eventually had the work authorized but only after more conversations
with the medical director who admitted to me he did not always understand
everything about prosthetics.
However, he also stated that if they disagree with even one code, they will
(and have a right) to deny the whole auth. As a side note, The PT doing O&P
authorizations in this state has previously told us the same, but admits
she is not that strict and will allow codes that are approved, denying
those not deemed necessary.
UHC has also told me they had stricter guidelines than Medicare and even
though the Medicare K-level verbiage states MAY be used for work,
exercise, etc for a K3; United told me their interpretation/standard was
the patient NEEDED to be using prosth for work, exercise, etc. to be
eligible for a K3 designation.
Regarding your K3 patient, you don't mention if he walks with variable
cadences, which is the major differentiator between K2 and K3. This also
has to be substantiated in the MD clinical note. We have had denials
because the MD does not document the need or appropriateness for a K3 foot
at the present time, and we are finding that UHC is now following the MD
notes as the primary supporting documentation for K level designation.

8 - Send an appeal and explain, just as you have here that the socket
replacement has no specified K level requirement. Send along a copy of of
the LCD on Lower Limb Prosthetics and tell them (don't ask) to provide you
with chapter and verse of the Medicare document on which they base their
claim....adding in the abscence of such documentation their check will be
very much appreciated. Be certain to follow all the instructions which they
provide for appeals.
 They have joined the ranks of denials anticipating no appeals as a
business model. Humana has lead the pack for years on that one.

9 -If you have support is your patient record describing the patient's
functional capability(ies) by describing the activities on a daily basis,
specifically mobility-related daily activities, that the person actually
uses prosthesis daily, every day or some measure of consistency/regularity
to support functional level classification, AND the patient's physician has
the same functional assessment information or a reasonable facsimile
thereof, that will suffice. It could also be emphasized that there are many
people walking around this Earth that are diabetic and functioning at a
VERY HIGH level - sports, recreation, employment, etc. Many are older, on
Medicare, and want to continue to be as active as possible - we must
provide the descriptive data, in the form of such a functional assessment
that details real-life activity of the patient/person/amputee.
Hope this helps.

10- I had a patient, last year for an AK socket replacement. UHC originally
denied because of the K level. I tried explaining that for a socket
replacement the only K level requirement should be the amputee meets a K1
level. The replacement was because of a surgical revision.
The patient had presented back as a K2 with using crutches, but still had a
potential to return to a K3 level after the socket replacement. However,
UHC denied because I documented she came in as a K2 at the time, with
potential for K3, when the prescribing MD wrote K3 on his notes; thus
denied because of the discrepancy.
We eventually had the work authorized but only after more conversations
with the medical director who admitted to me he did not always understand
everything about prosthetics.
However, he also stated that if they disagree with even one code, they will
(and have a right) to deny the whole auth. As a side note, The PT doing O&P
authorizations in this state has previously told us the same, but admits
she is not that strict and will allow codes that are approved, denying
those not deemed necessary.
UHC has also told me they had stricter guidelines than Medicare and even
though the Medicare K-level verbiage states MAY be used for work,
exercise, etc for a K3; United told me their interpretation/standard was
the patient NEEDED to be using prosth for work, exercise, etc. to be
eligible for a K3 designation.
Regarding your K3 patient, you don't mention if he walks with variable
cadences, which is the major differentiator between K2 and K3. This also
has to be substantiated in the MD clinical note. We have had denials
because the MD does not document the need or appropriateness for a K3 foot
at the present time, and we are finding that UHC is now following the MD
notes as the primary supporting documentation for K level designation.

11 -UH is rendering medical decisions that should only be done BY THE
PATIENTS PERSONAL PHYSICIAN WHO MANAGES THE MEDICAL
NEEDS OF HIS PATIENTS, NOT UH'S BEHIND THE SCENES MEDICAL
DIRECTOR who only reads records...you get my drift.

12 - Ask to see what Medicare guidelines they are referring to, chapter and
verse. I doubt that they will tell you, because it isn't true, but I would
ask, just to make clear what is going on. While it is true that Medicare
is auditing virtually every K3 or K4 claim, I do not believe that there is
anything in the PAs or LCDs that limits application that way.
Medicare has never used the functional level as a criteria for socket
replacements, although in the current broke-Medicare, RAC-driven
environment they may have written such a rule. And there is no replacement
policy or deeper qualification level than the current functional level
system. The presence of diabetes can certainly complicate function, and as
a group, diabetics are definitely in poorer health than those who aren't,
but the application of the K-level system is always determined at the
individual level, not the diagnosis level. That is probably the future
under Obamacare, and someone else awhile back posted a conversation they
had with one of their elected officials that described overt rationing of
health care, but that is not the situation now.
Short version, I think you are being scammed, either through intention or
incompetence. The incompetence factor might be the more probable, but
given that insurance companies of all kinds have a long history of finding
ways to deny whatever possible, it may be an intentional game on the back
of the Medicare turmoil. Either way they are not properly interpreting
Medicare policy.