Wiki Q4204 skin graft UHC denials

[TMacFarlane]

Hi,
wondering how everyone else is working the denials for Q4204 skin grafts for experimental/investigational for home health visits when billing UHC. We've been doing medical necessity letters and records to reconsider, but wondering if there is a way to get these paid without the denial reconsiderations.
Thanks!

 

[CBLENNIE]

According to the UHC policy I found for commercial plans, except for exchange plans in Colorado Skin and Soft Tissue Substitutes # 2023T0529T indicates that Q4204-Xwrap is considered not medically necessary due to insufficient evidence of efficacy. This policy is not specific to any servicing location so it would apply to home health IMO.

The disclaimer on the last page indicates it may also apply to MA plans in the absence of a Medicare NCD, LCD, or other Medicare coverage guidance. I did not find a NCD nor an LCD for Noridian Part B for Jurisdiction JF, which includes Idaho. So, I would say that the UHC commercial policy would also apply to any claims you may have for UHC MA plans.

So, I don't' know if there is a way for you to get paid for claims with Xwrap Q4204 billed on them to UHC based on this policy. Have you been able to get any claims with Q4204 paid when you appealed with the letter of med nec and medical records?

 

[TMacFarlane]

That's what I found as well. I actually did find the LCD/NCD that is being built but has a message at the top (similar to retired or superseded) that states it's still in progress so it's not yet finalized because of the absence of the medicare guidance.

 

[CBLENNIE]

I did not find an NCD that is in the proposal phase of development, I did find a couple of LCDs some were in draft form or finalized but they Part A&B MACs, none of the ones I found were for Noridian Jurisdiction JF. Here are the LCD documents I found:

• DA54117 Billing and Coding: Skin Substitutes for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers, Contractor: Novitas Solutions A&B MAC jurisdiction JH covering states Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania
• DL36690 LCD Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities, Contractor: CGS Administrators, A&B MAC jurisdiction J15 covering states Kentucky & Ohio and it also is the MAC for HH+H states Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming
• DA56696 Billing and Coding: Skin Substitutes for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers, Contractor: CGS Administrators, A&B MAC jurisdiction J15 covering states Kentucky & Ohio and it also is the MAC for HH+H states Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming

The HH+H MAC is jurisdiction J6 for Idaho is actually NGS (National Government Services, Inc.), I incorrectly advised that the MAC for Idaho is Noridian, but I forgot that HH+H providers are not governed by the Noridian as the Part B MAC for Idaho.

I searched the NGS website for HH+H LCDs in Idaho and nothing came up for Q4204 or Xwrap, so they do not have a policy in place at this time so again the UHC commercial policy I previously cited would be applicable to MA plans in Idaho.