Question UHC MEDICARE/64625

GMMTimmons

Contributor
Messages
20
Best answers
0
We have had issues with billing 64625 to UHC Medicare of Oklahoma. They paid these in 2020 and are now recouping and denying all 2021 claims. DX used is M47.818. Medicare Oklahoma pays these with no issue . Is anyone else having this issue?
 
Messages
3
Best answers
0
We have had issues with billing 64625 to UHC Medicare of Oklahoma. They paid these in 2020 and are now recouping and denying all 2021 claims. DX used is M47.818. Medicare Oklahoma pays these with no issue . Is anyone else having this issue?
Hello-all of our 64625 claims to UHC Medicare, Community Plan and Choice Plan are being recouped as well. Medicare does not have a LCD for the state of AZ so they keep referring me to their policies or a Medicare LCD that does not include our state or even our jurisdiction. Our claims are from 2020 also and one of their policies they are referring me to has an effective date of 02/01/2021 without mention of the policy being retroactive. I am trying to fight these although I do not believe they will overturn their recoupments. In their policy effective 02/01/2021, it does state that RFA for sacroiliac pain is unproven and not medically necessary--my issue is, all the other policies they are referring me to only talks about facet joints--Is the sacroiliac joint really a facet joint? I've been researching and everything I come across state the facet joints line each side of the vertebrae-so there are 2 per vertebrae. Which means there are facet joints coming down the spine to L-5, maybe S1? But I have not found any mention of the sacroiliac joint being a facet joint. UHC is the only one, right now, that is recouping all payments made for code 64625. Have you had any luck fighting the recoupments?
 

GMMTimmons

Contributor
Messages
20
Best answers
0
Hello-all of our 64625 claims to UHC Medicare, Community Plan and Choice Plan are being recouped as well. Medicare does not have a LCD for the state of AZ so they keep referring me to their policies or a Medicare LCD that does not include our state or even our jurisdiction. Our claims are from 2020 also and one of their policies they are referring me to has an effective date of 02/01/2021 without mention of the policy being retroactive. I am trying to fight these although I do not believe they will overturn their recoupments. In their policy effective 02/01/2021, it does state that RFA for sacroiliac pain is unproven and not medically necessary--my issue is, all the other policies they are referring me to only talks about facet joints--Is the sacroiliac joint really a facet joint? I've been researching and everything I come across state the facet joints line each side of the vertebrae-so there are 2 per vertebrae. Which means there are facet joints coming down the spine to L-5, maybe S1? But I have not found any mention of the sacroiliac joint being a facet joint. UHC is the only one, right now, that is recouping all payments made for code 64625. Have you had any luck fighting the recoupments?
No such luck. UHC's Medicare policy guideline #MCS070.01 Approval Date: April 20, 2021, says since there is no Medicare guideline for SI RF 64625 then we are to use UHC's commercial plan guideline. Their commercial plans do not cover RF's in the SI region.
 
Messages
3
Best answers
0
I wanted to let you know that I was able to get my Medicare recoupment claims overturned.

Per my provider rep, "After further review, I am going to clone this issue and overturn the Medicare claims. Procedure code 64625 was not listed on the Pain Management Reimbursement Policy for the DOS in question"

UID - Appeal/Inquiry - OVERTURNED: Based on the information provided we are withdrawing this overpayment from recovery. We have recovered the original refund requested on this claim, therefore the claim has been returned to the processing department for further adjustment. Please allow a minimum of 10 business days for this process to be completed and a corrected Explanation of Benefits to be generated. You can also review payment details on our website www.uhcprovider.com.

UID - Appeal/Inquiry - OVERTURNED: Based on the information provided we are withdrawing this overpayment from recovery. We have recovered the original refund requested on this claim, therefore the claim has been returned to the processing department for further adjustment. Please allow a minimum of 10 business days for this process to be completed and a corrected Explanation of Benefits to be generated. You can also review payment details on our website www.uhcprovider.com.

UID - Appeal/Inquiry - OVERTURNED: Based on the information provided we are withdrawing this overpayment from recovery. We have recovered the original refund requested on this claim, therefore the claim has been returned to the processing department for further adjustment. Please allow a minimum of 10 business days for this process to be completed and a corrected Explanation of Benefits to be generated. You can also review payment details on our website www.uhcprovider.com.



My Medicare recoupments were for the year 2020. Every policy they referred me to became effective AFTER 2021 and was NOT made retroactive. None of the prior policies specifically and purposely stated that 64625 was not covered. I fought it this way, as well as the Medicare LCD (A52863) they were using as "Source of Truth" tool, did not apply to my state, Arizona. When I called and spoke with someone at Medicare, they agreed that I should "push back" regarding use of an LCD that is not indicated for my state, jurisdiction and even wasn't the correct contractor.

I hope this info will help you.
 
Top