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Re: [IP] Medicare questions-appeal process



Kathy B. wrote:
"I'm sorry but this is not what Medicare covers for me.  My doctor has
written that I must change every two days and so they give me up to three
boxes every three months of the sets and the reservoirs.  I don't need all
the "r"'s but I do need the others."

Even with all the documentation, there can be times when Medicare denies,
and the appeals process (from the original post by us: "However, using the
appeals process with appropriate documentation usually results in a hearing
officer finding in "your favor") has to be followed since the basic, covered
by Medicare amount is 1 "catheter" set per week.
Below are excerpts from the letter Mike rec'd that the hearing
decision,which was initiated by National Diabetic Pharmacies on Mike's
behalf, was "Fully Favorable" -understand that all necessary documentation
for medical necessity has always been on file:

"The carrier [Palmetto GBA, the Region C durable Medical Equipment Regional
Carrier (DMEC) denied full payment for the catheter supplies [infusion sets]
because they believed Medicare does not usually pay for the total amount of
catheter supplies billed for the period of time covered by the claim...The
carrier stated in their letter that full payment for the catheter supplies
could not be made because Medicare does not usually pay for the total amount
of catheter supplies billed for the period of time covered by the claim
[48-4 boxes of 12, 90day supply as Mike's endo wanted him to be able to
change infusion sets q2da]...
Decision: [of  Robert E. Dremann, Medicare Hearing Officer] I have carefully
considered all of the information in the file for this claim.  I have
decided that the durable medical equipment you provided to the beneficiary
was reasonable and necessary for the diagnosis and treatment of illness or
injury or to improve the functioning of a malformed body member and is
covered by the Medicare program."

Guess the basic message is to appeal, appeal, appeal when there's a decision
made by Medicare that is not medically sound.
Marj; Mike (I'm not into computers, but glad to be on this list); and "Ace,
the PP" (portable pancreas)
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