Wiki Wellcare & UHC denials for DME dispensed after surgery

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TJAlexander

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I need help! I work for an orthopaedic practice for a provider that specializes in shoulder surgeries. He performs outpatient surgery in an on-campus outpatient hospital. After performing shoulder surgery, the physician assistant places a shoulder immobilizer (we use L3670) on the patient. The patient signs the DME delivery ticket and we send them on their way. Usually, we don't run into problems, however, I have two claims, one for UHC and one for Wellcare that indicate the DME is not payable when dispensed to a patient in a facility. I've never encountered this denial before and don't know how to appeal it. Neither UHC nor WellCare is able to point to a specific LCD that determines this policy. Nor are they able to point to their own specific policy regarding this matter. I'm considering an ERISA appeal to UHC because of this but I wanted to see if anyone else was having this issue and so, how are you addressing it??
 
No. These are shoulder immobilizers that we dispense after surgery. We are a Medicare DME supplier so we fit the patient after surgery and have them sign the DME delivery ticket. Our office manager hasn't wanted to give them the orthotics during pre-op in case the patient forgets to bring it. Either way, I am unable to find any published guidelines from CMS or UHC that specifically excludes payment in this situation.
 
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