Wiki Need help with Q4294

[bkhattak]

Medicare already paid but the supplement plan (Mutual of Omaha) is denying it for the LCD:
According to the LCD, repeat applications of skin substitute grafts when a previous application
was unsuccessful are not covered. Unsuccessful treatment is defined as an increase in size, no
measurable change from baseline, and no sign of improvement. According to the records
received, the repeat application did not meet the guidelines of the LCD.

I have never seen a supplement plan denying a claim for medical necessity. I would appreciate anyone's response.

 

[catherinetinkey@entmedicalservices.org]

You really need to be careful with skin substitutes. Medicare does cover most of them but for Medicare supplements, commercial supplements and Medicare replacement plans you have to research the coverage and criteria required by the plan. Most commercials plans do not cover skin substitute products. A patient's coinsurance on these products can be quite high. If the patient has a supplement that doesn't cover Medicare co-insurance the patient's bill can end up be very large.
Also documentation is the key, patient needs to show improvement, must document exact measurement of what was used and what was wasted plus how product was secured to patient, there can be no mention of infection.
Most of the companies that supply these products will do an insurance verification for the patient's plans before the procedure is done. If the secondary does not cover it you may want to discuss this with the patient.