Denial 33208 for Dx

kvogel03

Networker
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95
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Hello everyone,

I have received a couple denials 33208 with Medicare Plus Blue for diagnosis not meeting LCD criteria. I have received the article for 33208 and I have been using the diagnosis listed in the covered section with modifier KX. Reaching out to see if anything else has changed that I may have missed and to see if anyone else is having any issues.

Thanks,
 

vidraj

Contributor
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Buffalo Grove, IL
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Hi,

We have received denials stating the ICD doen't meet the NCD criteria.

We usually come across with patients having the primary diagnosis from this CMS list - I44.1, I44.2, I49.5 and Q24.6, which meets the criteria and the claim goes through with appropriate modifier.

Indications and Limitations of CoverageIndications and Limitations of Coverage(Reference link : https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=357)


B. Nationally Covered Indications
The following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:
  1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
  2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.
C. Nationally Non-Covered Indications
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers:
  1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
  2. Asymptomatic first degree atrioventricular block,
  3. Asymptomatic sinus bradycardia,
  4. Asymptomatic sino-atrial block or asymptomatic sinus arrest,
  5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
  6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
  7. Syncope of undetermined cause,
  8. Bradycardia during sleep,
  9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
  10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
  11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
  12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.
As long as it meets one of the above criteria and any additional modifier(s) needed as per your patient scenario (for example - Global Post op period) , I think it will be paid.
Lastly, we appeal with the medical record to find out the exact reason for denial, if none of this fits.

Hope this helps.
 
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