Re: Medicare DME Redetermination Request Form: How successful are folks at getting reimbursed? How many times to they have to resubmit documentation to achieve it? How much work is it for the supplier - who already is drowning in paperwork? How successful have you been with the new request form?
http://www.lymphactivist.org/redetermination_letter.php

For those cases that reach the third level of appeal, the Administrative Law Judge (ALJ) Hearing, my success rate has been running 60-70%. Recent changes in policy aimed at lowering the ALJ reversal rate of Medicare Contractor and RAC denials are lowering the ALJ reversal rate this year. This is one motivation in my suggestion of bringing in the medical and legal arguments at a lower appeal level so that we can have fewer denials at the first level of appeal, and avoid the long appeal time associated with the ALJ Hearing. ALJs are currently facing a 600,000-case backlog that is growing fast as Recovery Audit contractor (RAC) efforts have been restarted as part of Medicare attempts to reduce "overpayments".

The Medicare appeal system provides for five levels of appeal, only four of which are of practical interest, i.e. Level 1 Redetermination, Level 2 Reconsideration, Level 3 ALJ Hearing, Level 4 Medicare Appeals Council (MAC) Review.

Evidence documentation and arguments need only be submitted once, since it is placed in the Case File and forwarded to each higher level as the appeal progresses. The only other paperwork forms involved are one page appeal forms (CMS-20027, CMS-20033, CMS-20034) or abbreviated summaries (Beneficiary Name and health insurance claim number, description of specific items in dispute, date of service and name and signature of requester). I do not suggest that the Supplier conduct the appeal, but rather that the Supplier inform Beneficiaries of their rights of appeal. I have made appeal information available on this web site, and have a standing offer to assist Beneficiaries with their appeals
http://www.lymphactivist.org/approach_to_medicare_appeal.php.

The Supplier executes an Advance Beneficiary Notice of Noncoverage (ABN) to avoid any financial responsibility, and then files a claim with their regional DME MAC. When the claim is denied via Remittance Advice (RA) the Supplier can file the Redetermination Request, or do nothing further, leaving the Redetermination Request up to the now financially-responsible Beneficiary, who then responds to the denial using the form on their quarterly Medicare Summary Notice (MSN).

The only added paperwork I have suggested is to introduce a brief version of the rationale for the appeal that I use at ALJ hearing at the first level of appeal, which is where the issue should be resolved in the first place. The text I have suggested reminds the DME MAC of their statutory responsibility to make a benefit category determination as part of the initial coverage determination – a responsibility that they have not met in any denial I have seen in the ten years I have been involved in this activity. The argument for lymphedema compression items being covered as "prosthetic devices" can be made more consistent if an HCPCS L-Code is chosen to submit since this code group is used for prosthetic services. A-Codes only enable the mechanical process of denial on the basis that they do not meet the coverage requirements for "surgical dressings".

The suggested Medicare DME Redetermination Request Form may be found on the LymphActivist’s Site at http://www.lymphactivist.org/redetermination_letter.php. If the one-page CMS form CMS-20027 or the form in the MSN is used, it fulfills the information requirement and only the RATIONALE FOR DISAGREEMENT WITH INITIAL DENIAL need be appended.

I have not used this new approach yet at the first level of appeal and so I do not know how effective it will be in forcing the DME MAC to do their job as directed in the statutes and in the Medicare Claims Processing and Benefit Policy Manuals. I eagerly await feedback from the Beneficiaries, Providers and Suppliers who try this approach to receive reimbursement for the compression bandages, garments, devices and supplies used in their lymphedema treatment, which I believe meets all coverage requirements as prosthetic devices under Medicare law http://www.lymphactivist.org/prosthetic_devices-insert.pdf

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Lymphedema Treatment is Good Business as well as Good Medicine
© 2002 Robert Weiss, Porter Ranch, CA