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Getting denials from Humana, Humana Medicare stating that 17313, 17314 billed with dx C44.729 or C44.619 is not medically necessary. But, the LCD shows that the dx code is an approved dx to use for this procedure. What should I do?
Getting denials from Humana, Humana Medicare stating that 17313, 17314 billed with dx C44.729 or C44.619 is not medically necessary. But, the LCD shows that the dx code is an approved dx to use for this procedure. What should I do?
Is CGS your MAC? (I see your profile says Kentucky, but I'm unsure whether the services were also rendered in Kentucky.)
In the CGS LCD, those are Group 3 diagnoses:
Group 3 Paragraph
These ICD-10 codes should only be used when the surgery is done on the trunk, arms, hands, legs, or feet for one of the indications listed under "Basal cell carcinomas, squamous cell carcinomas, or basalosquamous carcinomas that have one or more of the following features" or "Squamous cell carcinoma exhibiting any of the following", in the Indications section of the policy.
You'll want to follow the instructions listed in the LCD:
"When billing for MOHS on the trunk or extremities, please insert one or more of the qualifying terms in the notepad of the electronic claim. (See "Indications and Limitations of Coverage.")"
Forgot to add: The LCD would apply to Humana Medicare.
If you're also having this issue with Humana Commercial, you may want to appeal with records demonstrating why the Mohs technique was medically necessary on the trunk or extremities for the specific patient. For Commercial patients, they don't have to follow the LCD. (Unless there's something specifically in the contract that states they will, I suppose.)