Wiki Retacrit Q5106 for Chemotherapy Induced Anemia

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LKaf7

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Patient presents to our outpatient clinical with an order to receive Retacrit due to chemotherapy induced anemia.

We are billing this to our MAC with the EA modifier, Value code 48, D64.81 and the cancer DX listed

I continue to get rejections with reason code 50 (deemed not medically necessary)

I am having no issues with the anemia due to CKD claims.

Is anyone else having issues with this or have any insight on what could be the problem? I have read the NCD/LCD over and over and I do not know what the problem is.

Thanks,
 
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We are with CGS. They told us it's because the EA mod however the LCD clearly states EA is needed. After walking the rep through the LCD guidelines, she escalated our issue and we are waiting for a call back. Who knows how long that will take. I have been appealing all of them successfully though.
 
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rachaelwilleford said:
Yes, we're having issues. Can't seem to resolve either. Hoping if I bump this, maybe someone else has found a resolution. FYI - We're with Novitas.
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Just wanted to share an update. It has been confirmed by CGS that our claims are processing incorrectly and sending the denial in error. They are working on getting it resolved. Until then, we just need to keep appealing. Perhaps the same thing is happening with your MAC.
 
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LKaf7 said:
Just wanted to share an update. It has been confirmed by CGS that our claims are processing incorrectly and sending the denial in error. They are working on getting it resolved. Until then, we just need to keep appealing. Perhaps the same thing is happening with your MAC.
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Thank you for the update. I have since changed employers, but I'll definitely let them know. Good to know!!
 
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