2015 brings some significant changes to payer guidelines. While you should be checking these regularly throughout the year, the new year is a good time to really go over them and address how they affect your practice. With the advent of new technologies, the world of Phlebology consistently needs newer strategies to ensure your patients services are covered by their insurance, or to identify when they are not.
Of note are some rather drastic changes made to the Novitas Medicare Contractor LCD policy. If this is your MAC, be sure to pull this policy from http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx and give it a thorough read as soon as you have a chance.
Some of the highlights are:
Conservative treatment now includes weight reduction to a BMI of <35, and an exercise program of calf muscle pumping exercises, along with the standard leg elevation and compression therapy. This policy also clearly defines exactly what training is needed by the provider of service in order to be considered a covered entity. This includes surgical services as well as diagnostic testing. Review against your current practice model to ensure compliance. The policy mentions specific vein diameters, including a whopping >10mm requirement for GSV or SSV! We feel this must be an error, but wanted to be sure attention was brought to this paragraph.
Guidance is clearly mentioned as not medically necessary for sclerotherapy and not covered separately. However, in a separate paragraph it does state it may be medically necessary in rare cases, and may be covered. Confusing, I know!
ERFA and EVLT are both clearly stated as not covered for perforator ablation.
Approved diagnoses have also changed, and deserves mention.
The above only covers a few of the details in this new LCD. We do advocate that providers submit commentary to Medicare regarding items that may be considered erroneous, and contact information is provided at the end of this article.
Another notable change is a requirement by UnitedHealthcare to wait on treatment for anterior accessory veins until after the GS and SS veins have already been treated. We have been made aware that authorizations for these veins are being denied when asked for in the same session.
We do not suggest that a provider change the way they treat a patient based solely upon what a payer dictates, but it is very important to be sure your patients are aware prior to treatment what services their insurance may not cover. If you do proceed with a planned course of treatment, an informed patient with the necessary paperwork on file will go a long way towards mitigating unpaid claims or preventing failure of an audit. For Medicare patients specifically, a current and completed ABN is required.
Unfortunately, MACs do tend to borrow language from each other. Keep a close watch on your state’s LCD in the future to be sure your policy hasn’t incorporated some of these changes.
Novitas Contact Information:
Per Novitas “Requests must be submitted in writing, and must identify the language that the requester wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD’s content or basis. Copies of published evidence included in your request must be full text articles.”
Requests can be sent to:
Office of the Contractor Medical Director
Novitas Solutions
(JH or JL) Medical Affairs Department
2020 Technology Pkwy STE 100
Mechanicsburg, PA 17050
Or by fax to: 717-526-6389
Or by email to:
Jurisdiction H – patricia.reidenbach@novitas-solutions.com
Jurisdiction L – vicki.kurland@novitas-solutions.com
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