Dedicated to Lymphedema Patients and the Therapists Who Treat Them
(Non)Coverage of Lymphedema Treatment
Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) to interpret Titles XVIII and XIX of the Social Security Act (SSA) and to implement the requirements of the SSA through a series of publications. Local administration is through a network of Medicare Contractors selected by CMS who either use the national publications or create local policies further interpreting the national policy or creating policy when a national policy does not exist.
Every service covered by Medicare must be medically necessary and must fit into a "benefit category" defined in the SSA. A specific item is covered if it meets the criteria set up for the specific benefit category, and it is denied if it is deemed not to be medically required or if it does not meet the coverability requirements for its benefit category.
STEPS IN A MEDICARE APPEAL
You must purchase your garments from a Medicare-enrolled Supplier who is registered with the National Supplier Clearinghouse. Furthermore, the physician or non-physician practitioners who order or refer must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and must be of the type/specialty who are eligible to order/refer services for Medicare beneficiaries. The orderer/referrer and enrolled Supplier federal enrollment numbers must appear on the prescription and invoice for the prescribed item.
If Supplier is a Medicare Supplier: Garment supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays garment supplier and gets a receipt. Make sure that this is the latest version of Form CMS-R-131 (03/08). This is important since the Section (G) Options were in reverse order from earlier versions. The option to be chosen is the only one that states in bold "I can appeal to Medicare". Also make sure that the referrer's and Supplier's Medicare enrollment numbers ore on this form together with the Supplier's address and phone numer.
When the Supplier files the claim for the Beneficiary, they will file on a Form 1500. Ask that they fill out Item 27 Acceptance of Assignment with a "NO", and further place the note "Beneficiary refuses to assign benefits" in Item 19.
If supplier is not a Medicare Supplier or is a Medicare Supplier but refuses to file a claim then the Beneficiary may submit a CMS Form 1490 Patient's Request for Medical Payment to Medicare requesting reimbursement for the garments purchased, and attaches receipt which has a full description of the items. Reimbursement, if won, will be sent directly to the Beneficiary since Block 6 Authorization says "... and request payment of medical insurance benefits to me" just above beneficiary's signature".
Medicare will send the denial directly to the Supplier in the form of a Remittance Advice (RA). The Beneficiary is informed of the denial when it appears on the quarterly Medicare Summary Notice (MSN). After the headers on this form, the sentence "This is a summary of claims processed from ... to ...". Following this there should be a section labeled "Part B Medical Insurance—Unassigned Claims". In the last column "See Notes Section" there will be a series of code letters denoting the reason for the denial. There will also be detailed instructions for appealing the decision. There is a 120-day appeal period after which no appeal will be allowed.
Beneficiary then consults Bob Weiss [LymphActivist@aol.com] to proceed further, i.e., several more denials will usually be necessary before the appeal goes to an administrative law judge (ALJ). At this point I will need a copy of the MSN and I will either guide the beneficiary in the first appeal, or I will file it on behalf of the beneficiary. If you wish me to file as your representative you execute an Appointment of Representative CMS Form 1696.
This first appeal is called a "Redetermination", made to an "independent" Medicare Contractor called a DME Medicare Administrative Contractor or "DME MAC" for your region. After the DME MAC supports the denial, you indicate that you disagree with the decision and appeal by requesting a "Reconsideration" by a "Medicare Quality Independent Contractor" or QIC. Neither the DME MAC nor the QIC understands the concept of "benefit category", which is the mechanism in the Social Security Act that confers coverage. The next appeal is to an Administrative Law Judge (ALJ) which is the first hearing where you can get a "fair hearing" by an agency which is obliged and capable of looking at the law.
None of these appeals costs any more than the cost of making copies and postage. There is a 60-80% chance of a favorable determination by the ALJ. In the event that the ALJ renders an unfavorable decision then we will appeal to the Medicare Appeals Council, where I run about a 25% favorable rate.
The Supplier has little incentive to file your claim and appeal. The supplier receives a reduced amount of reimbursement from the retail price of the item, and if they are a Medicare-enrolled Supplier they are required to file a claim for something they know will be denied. So they will ask for payment in advance. So as long as they are filing on behalf of the beneficiary it is important for the beneficiary to refuse to "assign benefits" on the Form 1500. That way there will be no refunds necessary and the reimbursement check (minus deductibles and co-pay) will come directly to the Beneficiary.
(Thanks to therapist Kevern Hartmann for providing the framework for this piece and forcing me to research the appeal process. I would ask any reader who discovers any errors or changes o the process to contact me immediately. Please remember that I am not allowed to provide medical or legal advice. All I can do is to read the appropriate regulations and policies and tell you what my understanding is.
(From Manual Lymphedema Drainage Therapy LCD Pennsylvania Highmark Medicare Services LCD Number Y-11C)
The medical record documentation maintained by the provider must clearly document the medical necessity of the services being performed.
APPROACH TO A MEDICARE APPEAL
The approach I have taken in appealing Medicare denials of lymphedema treatment are to show that: 1) the treatment service or item are medically necessary; 2) is it is part of a medically recommended treatment guideline and is prescribed by the patient's physician; and 3) it falls into a benefit category covered by the Social Security Act.
Specifically, I show that manual lymph drainage (MLD) performed by a specially-trained therapist in accordance with a physician-approved treatment plan determines the frequency and duration of the clinical treatment. The policies on treatment duration established for rehabilitative therapy do not apply to this medical procedure, and that the length of the treatment is determined by medical necessity.
Furthermore, I show that compression bandages, garments and devices fall into the "prosthetic devices" benefit category defined by §1861(s)(8) of the Social Security Act. CMS Publication 100-2, Chapter 15, §120 defines a prosthetic device as follows: "A. General.-- Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered when furnished on a physician's order."
In this case the inoperative or malfunctioning internal body organ is the lymphatic system and the compression items replace all or part of its function.
There are no Medicare coverage determinations or policies dealing with compression bandages, garments or devices when used in the function of treating lymphedema, so Medicare Contractors (and healthcare insurers) select policies which deal with materials which look similar but are used in a different function, and apply the coverage criteria for the other use. They obviously fail and are denied.
Compression bandages are denied for home use because the benefit criteria they are placed into is "surgical dressings", which are non-durable supplies used in an in-patient procedure in conjunction with treatment of an open wound. This is hardly the function of a short-stretch bandage, tubular sleeve or gauze finger bandage in the treatment of lymphedema! My argument is that the assemblage of these diverse materials every night on the lymphedema patient's arm or leg is a prosthetic device which is assembled to the exact medical requirements at that time by a patient or an aide who has been instructed in the specific techniques. It makes no more sense to deny a bandage system because its components are not covered than it would be to deny a wheelchair because its wheels or axle are not separately covered. What matters is the function of this totality of parts in the treatment of lymphedema that determines coverability.
Compression garments are frequently denied either because they "are not medically necessary" or because they do not meet the requirements of "secondary surgical dressings". The first issue is easy to address by showing that these are different from "support stockings" which are worn as comfort or convenience items, not necessarily with physician's prescription. These are required for daily use as part of the medical standard of care of lymphedema. [reference to ISL, ACS, NLN consensus recommendations]
The second argument is more difficult to counter since 2006, when CMS moved the coding of compression stockings from the prosthetic devices category with HCPCS codes Lxxxx to the surgical dressing category with HCPCS codes Axxxx. The criteria for coverage of a compression stocking as a secondary surgical dressing is that it be used with one or more primary dressing in the treatment of an open venous stasis wound. Denied!
So my approach has been to show that compression garments and devices meet the prosthetic device requirements of the SSA, and are therefore not subject to the surgical dressing coverage criteria. So far eleven Medicare Administrative Law Judges have agreed and have ruled that the Medicare patients must be reimbursed for their garments (upper limbs and lower limbs).
APPEALING AN UNFAVORABLE MEDICARE DECISION
Compression is the mainstay of lymphedema treatment and denial of the medical materials which enable the patient to treat their lymphedema is tantamount to denial of medical treatment. And this is a breach of the insurance contract.
(courtesy of Medicare Rights Center "Dear Marci" Column)
If you have traditional Medicare (Part B), your appeal must be submitted within 120 days of the date on the MSN denying coverage.
If you receive your Medicare through a private plan, like an HMO or a PPO, you only have 60 days to submit your request for reconsideration. The plan then has 60 days to make a decision for post-service denials (but only 30 days for pre-service denials).
If the plan upholds the denial, the case is forwarded to an independent reviewer who must also make a decision to uphold or overturn the HMO's decision within 30 days for care or 60 days for payment. For more information on this independent reviewer, visit its web site listed in the Spotlight on Resources below.
If you think you have a good reason for not appealing on time, send in your appeal with a clear explanation of why it is late.
Medicare Appeals — The Importance of Getting it to the Right Place at the Right Time!
(Courtesy CIGNA Government Services, Medicare DME MAC C, Part B ID & NC)
Over the past year, the Qualified Independent Contractor (QIC) Part B North (the processor of second — level appeals or reconsiderations) has consistently made a high rate of dismissal decisions. Based on data analysis, the driving factor in this high rate is that appellants, primarily providers, request reconsideration when a redetermination (first level appeal performed by CIGNA Government Services following the processing of the original claim) has not been completed.
While often the cause appears to be simply confusion over the steps of the appeals process and the parties involved, we have also noted that some providers are confusing written and telephone inquiry responses from CIGNA Government Services with official redetermination decisions. In accordance with current instructions, contractors are required to issue a written notice of redetermination. If you disagree with this decision, you may then file a reconsideration request in writing with the QIC.
Your first level appeal, a redetermination, is performed by the contractor who processed the original claim and those requests should be sent directly to CIGNA Government Services. Sending a first level appeal request to the QIC will result in a dismissal.
Lastly, please be sure your request details specifically all the claims you are requesting an appeal on, including the beneficiary's name, the Medicare Health Insurance claim number, the dates of service at issue, the services at issue, your reason for appealing, the name and signature of the party or representative of the party, and the name of the contractor that made the redetermination.
WRITE A LETTER OF MEDICAL NECESSITY FOR YOUR DOCTOR TO SIGN
HELP AVAILABLE IN YOUR APPEAL
I help patients appeal denial of compression bandages, garments and devices. It is a lengthy process, taking 1-4 years, with not at all an assured outcome, but it is worth the trouble since I am using the successful cases to convince CMS to change their interpretation of the Social Security Act and to cover lymphedema treatment materials. Every claim filed adds to CMS's realization that there is a real problem that needs addressing, and every case won adds to the credibility of the prosthetic device interpretation of the federal statutes.
I do not charge any fees for the work I do. I expect that the patient therapist or provider to appeal the first denial, and when that appeal is upheld (and it will be) then I will help writing the Redetermination Request. For Medicare cases, when that is denied, I will ask to be designated the Authorized Representative and I will write and submit the Reconsideration Request for an "independent determination" by a Medicare Qualified Independent Contractor. I will at that time generate an evidence package for use at a Medicare Administrative Law Judge hearing. This is the first level of appeal at which we have a chance of winning the appeal and being reimbursed.
Contact me when you are denied reimbursement.
Robert Weiss, M.S.
Lymphedema Treatment Advocate
The above is solely the opinion of a lay patient advocate, and is not to be interpreted as legal or medical advice. Please consult a properly qualified professional before taking legal or medical action in your specific case.
Compiled February 26, 2008.
Revised December 3, 2009.
Revised April 14, 2010.