Be on the lookout for DRAFT LCD denials disguised as current, in-force LCD denials

Be on the lookout for DRAFT LCD denials disguised as current, in-force LCD denials

William Lifford

5/20/2020

Hello colleagues,

To those of you who work with Empire BCBS Medicare Advantage amputees --
please be on the lookout for unusual or improper code denials on your
prior-authorization requests.

Some examples would be things like these:

L5968 (hydraulic ankle) denied for K2 patients, stating that L5968 is
covered for K3 and above

L5645 denied as duplicative when part of the same prosthesis that
includes gel/silicone/urethane liners



These Medicare Advantage denials -- where Empire BCBS says they are based
on the current, in-force LCD coverage criteria -- are NOT VALID or true.
They are based on lies.

The denials for these codes (and there are some others, too) are based on
the coverage criteria in the DRAFT LCD. Yes, that's right, the Draft LCD
that was *never* put in-force and was *retired*. Somebody over at Empire
(or possibly from some other company that does consulting work for them) is
using the Draft LCD criteria to justify denying codes from Medicare
Advantage prior-auth requests, and then lying to you and your patients to
make it seem like they are using actual, in-force LCD coverage criteria.

PLEASE CONTACT ME IF YOU EXPERIENCE SUCH DENIALS. I AM ACTIVELY WORKING ON
MAKING EMPIRE AWARE OF THE SITUATION AND I COULD USE ALL THE HELP I CAN GET
(meaning supporting information... just block out the PHI to
protect patient identities). I have some people who are willing to hear
me out on this; I'd like to have info from more than just my facility.

Thanks so much for any assistance you can provide, and I wish you and your
families health and safety in these weird and stressful times.

Bill Lifford, CP



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