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PostPosted: Sat Jun 30, 2007 8:32 pm
by patoco

July 1, 2007

Start by asking your dealer to send in a Medicare reimbursement claim (even though you know that they will deny the request). They may ask you to sign an Advanced Beneficiary Notice of Non-payment (ABN). That's OK.

If your dealer will not file a claim then ask them to help you file a CMS-1490 Beneficiary Claim Form. I am attaching one to this message. Make sure that the bill for the graduated compression garment (Do NOT call it a "support garment" since support garments are not covered) has an L-code and not an A-code. Use L-8220 Gradient Compression Stocking, Lymphedema for a lower limb garment, S-8420-8428 for an upper limb garment. Make sure that Block 4 on the form includes a diagnostic code for lymphedema (e.g. 457.0 post-mastectomy lymphedema, 457.1 lymphedema, other than post-mastectomy or 757.0 congenital lymphedema lower limbs). Please read the instructions on page 2 of the form. Don't forget to send a copy of the invoice for the garment with the other information called for. Also make sure that the provider uses the code numbers above.

Start collecting documentation from your doctor and your therapist that will be used to conduct the appeal after your request for redetermination is denied.

Get letters from your physician and therapist that would include the following:
• a physician-documented diagnosis of lymphedema with diagnosis code;
• a statement as to the ability of the patient/caregiver to follow through with the continuation of treatment per the long term home treatment plan;
• the medical necessity of each treatment or supply;
• history and physical examination summary which address the cause of the lymphedema, describing any prior treatment. It must also address the symptoms which necessitate treatment and diagnosis of any co-conditions which would complicate lymphedema treatment (e.g. obesity, congestive heart condition, venous insufficiency, peripheral arterial disease, etc.);
• measurement of body part/extremity prior to treatment;
• a report showing the progress of the therapy which should contain measurements showing a reduction in size of the extremity. This should also address the response of the patient/patient caregiver to the education and their understanding and ability to take on some of the responsibilities of the treatment. This progress report must also address the expected outcome of the treatment as well as the expected duration of treatment;
• prognosis with treatment and without treatment, specifically relating under-treatment of lymphedema with an increased risk of infection (e.g. lymphangitis, cellulitis), disability and lymphangiosarcoma.

Get a copy of the physician's referral to the therapist and a prescription for the compression supplies that are being denied.

After the redetermination requests are denied, I will help you with the next step, a request for reconsideration, which will be sent to a Medicare Quality Insurance Contractor. This request will also be denied, but then enables us to appeal to a Medicare Administrative Law Judge. This is the key level, and is the first point where you will get a fighting chance to win your case. It is unfortunate that we must go through all the other hoops first, just to get to this point.

I will ask you, at some point, to authorize me to be your representative in this matter. I'll send you the form to be filled out at that point. At no time will I ask you for any payment for my services, and I will sign a waiver of all fees or remuneration on the authorization. In the meantime you can send copies of the Medicare Summary Notice (MSN), prescription and your correspondence with Medicare and your provider or insurer to me at:

Robert Weiss
10671 Baton Rouge Avenue
Northridge, CA 91326-2905.

Please remember that every great journey begins with a single step. The process is long and tedious, and there is no guarantee that you will ultimately win, but you must be one of the brave ones who fights for your rights and helps change the system.

Looking forward to helping you.

Robert Weiss, M.S.
Lymphedema Treatment Advocate

Tel: 818-368-6340
Fax: 818-368-6432

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This is great Bob, as always we so appreciate your input and advice!!!

Pat O'Connor
Lymphedema People