L1843 with dx 715.96 for patient who has for it 10yrs

L1843 with dx 715.96 for patient who has for it 10yrs

Annaldasula CPC, Padmavathi S.

2/6/2014

Hi,

I am in shock now and with ALJ appeals suspended what do we do. Who do I file a complaint with. I have a L1843 denied for dx 715.96 for patient who has it for the past 10 yrs, we also have an abn signed by the patient reason clearly noted Medicare considers this item not medically necessary for your condition and yet the C2C DME Medical Director denies the claim without patient responsibility.

Here is the exact wording on the denial letter:
The medical documentation on record does not indicate the beneficiary has had a recent injury or surgical procedure on the knee. The documentation on record indicates the beneficiary has diagnosis of osteo-arthritis(715.96), which is not a covered diagnosis according to the LCD criteria. As such , the record has not satisfied all requirements for the item at issue according to Medicare policy. Therefore payment cannot be effected for the knee orthotic, due to lack of medical necessity.

I have checked online for C2C Medical Directors credential, believe me pretty impressive, but did the MD review the appeal. It seems like the MD specialty is internal medicine. Now I wonder

1. if a Medical Director even reviewed this claim

2. Does the Medical Director even know DME Medicare policy in place for this.

3. Did MD even read the policy in its entirety.

4. an internal medicine specialist reviewing an orthopedic providers supply given in the office.

Policy clearly met even the diagnosis match so why would they still deny the supply. With ALJ suspended no patient responsibility given we are stuck with the liability.
For future reference I am trying to understand what did the reviewer look at to deny the service.

What are my options to going to congress is one but at the ground level what are my options.

Thanks,
Padma Annaldasula CPC


> *CONFIDENTIALITY NOTICE: This electronic communication contains confidential information. It may also be privileged work product or proprietary information and is intended for the exclusive use of the person(s) whose name(s) is(are) indicated above. If the reader of this notice is neither the intended recipient, nor the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any use, dissemination, distribution, or copying of this information, including any attachments, is strictly prohibited. If you have received this electronic communication in error, please notify the sender immediately via return email or by calling at the phone number shown above and deleting the original email message (including attachments) and any copies or backup copies from your computer system. Thank you.