A funny thing happened on the way to an appeal today. When I educate providers on researching LCDs for Medicare appeals, I always recommend accessing the LCDs through the CMS Coverage Database https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx rather than through the FI or MAC website because I have often found that the LCDs on the CMS website are more current than the LCDs you will find posted on the FI or MAC website. Don’t ask me why, but that has been my experience.
This week I have been working with one of our nurse reviewers on a case for a client in the Highmark Medicare Services, Inc. MAC district. A patient has been receiving HBO therapy and services were paid by Highmark for sessions one and two, but session three provided on 6/17/2011 was denied via EOB as reason code 50 Not Medically Necessary. The cliams for all three sessions carried the ICD-9-CM diagnosis code of 990 Effects Of Radiation, Unspecified. So, of course, the first place we went was the CMS Coverage Database to review any NCDs or LCDs for HBO therapy and in fact, there is an NCD for HBO therapy (20.29). The NCD lists both osteoradionecrosis and soft tisuue radionecrosis as conditions that are covered for HBO therapy. The NCD itself, however, does not list specific ICD-9-CM codes.
On to the LCDs. Using the CMS database we found that Highmark issued an LCD for HBO therapy that went into effect, wouldn’t you know it, on 6/17/2011, the same date as the denied service. We quickly scanned the LCD looking for the inclusion or exclusion of ICD-9-CM 990. It wasn’t included on the list of covered ICD-9-CM codes for HBO therapy! It seemed to us that it should have been there as a covered diagnosis. Well, now we knew we were dead in the water. There really wasn’t a chance for appeal when the LCD does not include the ICD-9-CM code for this patient as a diagnosis that supports medical necessity. If I had stopped there, I would have had to tell the client that there was no chance for appeal, but this just did not seem fair. The patient had already been receiving HBO therapy that was being paid by CMS and now suddenly therapy would no longer be covered. I realize that LCDs have to have an effective date, but this just didn’t seem right.
So the nurse reviewer and I did some more digging. Going back to the NCD, under ‘Revision History’ I found a transmittal (TN 164 – CR 2388) that indicated that ICD-9-CM 990 is a covered diagnosis for HBO therapy. Since LCDs are not allowed to be more restrictive than an NCD, I knew we had the evidence we needed to appeal this HBO denial. The funny thing that happened though is that the nurse reviewer went on the Highmark website and looked at the HBO LCD (L32018) for services performed on or after 6/17/2011 (the same one posted on the CMS website) and ICD-9-CM 990 was included in the list of covered diagnosis! And in fact, the revision history for the LCD included a revision made on 6/17/2011, the same day the LCD went into effect, that reads “Revision effective for dates of service on and after 06/17/2011. ICD-9 code 990 added for coverage”. Well, what do you know? The LCD from the Highmark website will make it even easier to appeal.
What I learned is this, if it doesn’t seem right, it probably isn’t. Just keep digging and you’ll find the right answer. I guess I also need to rethink my standard teaching method of always accessing the LCDs from the CMS database. I now know there may be times when I need to look at both the CMS database and the FI or MAC website. Just shows you what a little digging and a refusal to accept ‘No’ for an answer will get you! And kudos to the nurse reviewer who worked with me on this!
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