Why Did I Receive This Denial?

Why Did I Receive This Denial?

July 25, 2019

Question:
Our surgeon performed a meniscectomy on a Medicare beneficiary.   During the 2nd post-operative visit, the surgeon started a series of Hyaluronate injections in the operative knee for a diagnosis of osteoarthritis.  The claim form was submitted with a modifier 79 and a diagnosis of osteoarthritis.   Our Medicare carrier denied it as “not medically necessary” and transferred the financial responsibility to the surgeon. We are at a loss as to why this occurred.  Of course, we did not have an ABN as we never expected such a denial.

Answer:
Thanks for your inquiry. At face value, it makes total sense to question this denial.  The answer will depend on who your Medicare carrier is and LCDs that cover your state.  For example, if you are in a state where Novitas is the carrier, the LCD L35427 includes the following policy statement excerpt:

“Viscosupplementation is considered not medically reasonable and necessary at the end of a knee surgical procedure or during the postoperative period following a knee surgical procedure (e.g., anterior cruciate ligament [ACL] reconstruction or arthroscopic meniscectomy). It would be expected that use of viscosupplementation would not be initiated until after the patient has made a full recovery from the knee surgery (individualized for each patient); and the patient is symptomatic with a diagnosis of osteoarthritis; and clinical presentation meets the covered indications as stated.”

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35427&ver=68&Date=&DocID=L35427&bc=iAAAABAAAAAA&

The denial was most likely triggered when the claim was processed with modifier 79 and the diagnosis indicated the condition was in the same knee as the operative knee for the meniscectomy.

The practice must write off the service as a non-contractual adjustment as an ABN was not obtained and Medicare transferred financial responsibility to the physician/practice.

*This response is based on the best information available as of 07/25/19.

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