Lymphland International lymphedema online (LILO)
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  • In Memory of Julie Frary, Co-owner of Lymphland International Lymphedema Online
  • Memorials to those who died of lymphedema (and treating doctors who died as well)
  • Abstracts 2013

The unwritten policy called the "improvement standard" used by Medicare Contractors to deny any therapy that does not result in measurable functional improvement has been thrown out by a Federal Judge. This means that Medicare beneficiaries who require skilled maintenance services cannot be denied those services in the home health, nursing home or outpatient setting. This settlement becomes effective today, January 24, with the signing of the Settlement Agreement in the Jimmo v. Sebelius Medicare Improvement Standard case.

CMS has been tasked to educate its contractors and to change its documentation, policies, guidelines and instructions. In the meantime, if medically required therapy that has been prescribed by your physician in treatment of your lymphedema has been denied on the basis that there is no expected functional improvement, file an appeal.

It will be very interesting to see how this law will affect the implementation of the new therapy reimbursement policies scheduled for 2014, which are based on demonstration of functional improvement.


January
23, 2012


PECOS  Warning Edit Change (CEDI Message)
Effective
January 01, 2012 the durable  medical equipment Medicare administrative
contractors (DME
MACs) began  to return warning messages if the
ordering or referring provider on the claim is  not eligible to
order or refer DME supplies as determined from Provider  Enrollment
Chain & Ownership System
(PECOS). These messages are  returned
on the electronic remittance advice (ERA) or standard paper remit
(SPR) with the following remittance advice remark code (RARC) and will
  apply to both 4010A1 and
5010A1 formatted claims:
N544 - Alert:
  Although this was paid, you have billed with a referring/ordering provider that
  does not match
our system record. Unless, corrected, this will not
be  paid in the future.
Through January 29, 2012 the Common Electronic Data
  Interchange (CEDI) will continue to return the
PECOS warning edits
for  4010A1 claims on the GenResponse Report.
The Centers for Medicare &
  Medicaid Services (CMS) and the DME MACs will communicate when the
edits will become denials when that date is determined.

President
  Obama Signs the Temporary Payroll Tax Cut Continuation Act of 2011
  (TPTCCA)Section 304
of the TPTCCA extends the exceptions process
for  outpatient therapy
caps.  Outpatient therapy service providers may
continue  to submit claims with
the KX modifier, when an exception is
appropriate, for  services furnished on or
after January 1, 2012, through
February 29, 2012.  

The therapy caps are determined on a calendar year
basis, so all  patients begin
a new cap year on January 1, 2012.  For
physical therapy and  speech language
pathology services combined, the limit
on incurred expenses  is $1,880.  For
occupational therapy services, the
limit is $1,880.  Deductible and coinsurance
amounts applied to therapy
services count toward  the amount accrued before a cap
is reached, and also
apply for services above  the cap where the KX modifier
is
used.

Robert Weiss,  M.S.
Lymphedema Patient
Advocate
National Lymphedema Network



-----------------------

The
official  medicare website is located at :

http://www.medicare.gov/



How to find a
  prescription plan under medicare:

http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C6%
7CWinXP&language=English&defaultstatus=0&pagelist=Home&View&PDPYear=2006&MAPDYear=2006&MPDPF%5FMPPF%
5FIntegrate=N

From the looks
of  it there are 2 types of plans you can join:

Plans include HMOs, PPOs,
and  Private-Fee-for-Service plans. They offer complete Medicare-
covered  health care, including drug coverage, through a single plan.
Most of these plans  generally
offer extra benefits and lower
copayments than the Original  Medicare Plan. However, you may
have
to see doctors that belong to the  plan or go to certain hospitals to get
services.

FROM NORD  again:

Knowing Your Health History Could Save
Your Life

Most  Americans believe that knowing their family health
history can be beneficial,  but only about
one-third have actually
tried to gather and record  information about family health, according to a
recent study by the  U.S. Centers for Disease Control and Prevention
(CDC).

Furthermore, the  discussion of family history between physician
and patient typically lasts just  a
few minutes.

"But knowing
your family history can save your  life," US Surgeon General Richard H. Carmona

said at a press conference  in November to launch a project known as
the Family History
Initiative.  As part of this project, the
Department of Health and Human Services has created  a
new
computerized tool, called "My Family Health Portrait," that can  be downloaded
at www.hhs.
gov/familyhistory/ to help in the
  process.

Francis S. Collins, MD, PhD, director of the National Human
  Genome Research Institute, noted
that all people have genetic
  abnormalities that make them more susceptible to certain illnesses.
Tracking illnesses from one generation of a family to the next can help
  identify illnesses for which
the family is at risk. This may allow
  family members, working with their physicians, to take steps
to
reduce  their risk.

The tool guides users through a series of screens to
record  information for each family member
about six common
diseases. Other  conditions may also be added. After the information has been

collected,  a diagram can be printed and shared with a
physician.

All personal  information is maintained on the user's
computer. No information is given to the
government. Eventually, the
tool will be available in both English and  Spanish. Also, a print
version will be provided to those who call the  Federal Citizen
Information Center at (888) 878-
3256.

The  federal employees
who have worked on this project, from the National Institutes  of Health,
Surgeon General's office and CDC, hope families will take  advantage of
being together over the
holidays to compile a health  history. "It
is our hope as families gather this holiday season, they'll
take the
time to learn-and record-their families' health histories so that  they can
continue to have
years of family gatherings together," said  Muin
Khoury, MD, director of CDC's Office of
Genomics and Disease
  Prevention.



MEDICAID ALERT:

Medicare/Medicaid Information
  regarding insurance with medicare:

You automatically qualify for extra
  help and don't need to apply if you:

have Medicare and full coverage
from  a state Medicaid program that currently pays for your
prescriptions.  You should join a plan that meets your needs by December
31, 2005 because
Medicaid will no longer pay for prescription drugs.
If you don't, Medicare  will enroll you in a plan
effective January
1, 2006 so you don't miss a  day of coverage. You can drop the plan or switch to

another any  time.


get help from your state Medicaid
program paying your Medicare  premiums (belong to a
Medicare Savings
Program). You should join a plan  that meets your needs by December 31, 2005.

If you haven't signed up by  May 15, 2006, Medicare will enroll you
in a plan effective June 1,
2006  so you don't have to pay a
penalty. You can drop the plan or switch to another  any time.


get
Supplemental Security Income. You should join a plan  that meets your needs by
December 31,
2005. If you haven't signed up by  May 15, 2006,
Medicare will enroll you in a plan effective June
1, 2006  so you
don't have to pay a penalty. If Medicare enrolled you in a prescription  drug
plan,
you can switch to another plan one time before December 31,
  2006.
---------------------
What To Do
When  Medicare Says
  'No'
http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state=

Your
  doctor suggested you have a minor operation or procedure, you went ahead and
had  it done, and now
Medicare won't pay for it. What should you do?
  Appeal.
Your provider tells you that your lymphedema compression garments
are  not covered. What should you
do? Appeal. [Added by Bob
  Weiss]

Medicare covers procedures that are deemed medically necessary.
  "Appealing is easy and most people win
so it is worth your while to
  challenge a Medicare denial," says the Medicare Rights Center, a national
nonprofit organization. The denial of coverage may be due, for example,
to  a simple coding error in your
doctor's office.

People
have a  strong chance of winning their Medicare appeal. According to Center, 80
percent  of
Medicare Part A appeals and 92 percent of Part B appeals
turn out in  favor of the person appealing.

The Medicare Rights Center
offers the  following tips to maximize your success when appealing your
denial:

a..  Write "Please Review" on the bottom of your Medicare Summary
Notice (MSN), sign  the back and
send the original to the address
listed on your MSN by  certified mail or with delivery confirmation.
b..
Include a letter explaining  why the claim should be covered.
c.. When possible, get a letter of support from your doctor or other health care provider explaining why the
service was "medically
necessary."
d.. Save photocopies and records of  all communications, whether
written or oral, with Medicare concerning
your denial.
e.. Keep
in mind that you only have up to 120 days from the  date on the MSN to submit an
appeal.
The Center notes that the appeals  process is slightly different if
you are in a private Medicare plan, like an
HMO or a PPO. One
difference is that you have only 60 days from the date on  the denial notice to
file an
appeal.

Resources:

For  information on how to
fight a hospital discharge, click here.

For more on  the Medicare Rights
Center, visit its Web site at  http://www.medicarerights.org

To download
Medicare appeal forms from the  government's Medicare website, click
  here.



--------------------------------------------------------------------------------------------

FILING
  A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS


* Garment supplier fills out an ABN and gives Beneficiary a copy. Beneficiary pays garment fitter and gets a
receipt. Make sure that this is the
latest version of Form  CMS-R-131. I have the version dated (03/08).
This is important since  the Section (G) Options were in reverse order
from earlier versions. The option  to be
chosen is the only one
which states in bold "I can appeal to  Medicare".

* If the Supplier should choose to file the claim for the beneficiary, they will file on a Form 1500. Ask that
they fill out Item  27 Acceptance of Assignment with
a "NO", and further place the note "Beneficiary  refuses
to assign
benefits" in Item 19. (see note below why Supplier  may not be motivated to file
for the beneficiary).

* Beneficiary submits  CMS form 1490 Patient's
Request for Medical Payment to Medicare requesting
reimbursement for
the garment listed on the ABN, and attaches receipt.  Block 6 Authorization says
"... and
request payment of medical  insurance benefits to me." just
above beneficiary's signature.

* Medicare  sends a denial directly to the
Beneficiary. Denial appears on the quarterly  Medicare Summary
Notice (MSN). After the headers on this form, the  sentence "This is a
summary of claims processed from ...
to ...".  Following this there
should be a section labeled "Part B Medical  Insurance-Unassigned Claims". In

the last column "See Notes Section"  there will be a series of code
letters denoting the reason for the denial.
There will also be
detailed instructions for appealing the decision. There  is a 120-day appeal
period after
which no appeal will be  allowed.

* Beneficiary
consults Bob Weiss [LymphActivist@aol.com] to  proceed further, i.e., several
more denials
will come down the pike  before it goes to an
administrative law judge... At this point I will need a  copy of
the
MSN and I will either guide the beneficiary in the first  appeal, or I will file
it on behalf of the beneficiary.
This first  appeal to an
"independent" Medicare Contractor is called a "Redetermination",  the next
appeal to a
"Medicare Quality Independent Contractor" or a  "DME
MAC" is a "Reconsideration", and the next appeal
is to an
  Administrative Law Judge (ALJ). None of these appeals costs any more than the
  cost of making
copies and postage. There is a 60-80% chance of a
  favorable determination by the ALJ. In the event that
the ALJ
renders  an unfavorable decision then we will appeal to the Medicare Appeals
Council,  where I run
about a 50% favorable rate.


IF the
Beneficiary  gets reimbursed after 2 years or so, the ABN states that "If
Medicare does pay,  you will
refund any payments I made to you, less
co-pays or  deductibles."  This puzzles me.   Does this mean that
Medicare will  reimburse the garment fitter directly?   (That's crazy
because it is definintely  not in a garment
fitter's interest to go
to the trouble of submitting  an ABN for a Beneficiary only to have to refund
their money
at a later  time). You are correct that the Supplier has
little incentive to file your  complaint. The supplier
receives a
reduced amount of reimbursement from  the retail price of the item, and if they
are a Medicare
Supplier they  are required to file a claim for
something they know will be denied. So they  will ask for
payment in
advance. So as long as they are filing on  behalf of the beneficiary it is
important for the
beneficiary to refuse  to assign benefits on the
Form 1500. That way there will be no refunds  necessary.

(Thanks to
therapist Kevern Hartmann for providing the  framework for this piece and
forcing me to
research the appeal process.  I would ask any reader
who discovers any errors or changes to the process to
contact me
immediately. Please remember that I am not allowed to provide  medical or legal
advice. All I
can do is to read the appropriate  regulations and
policies and tell you what my understanding is.)

Robert  Weiss,
M.S.
Lymphedema Patient Advocate
LymphActivist@aol.com
--------------------------------------------------------------------------------------------

Abstracted
  this from an article in the San Francisco Chronicle. This applies to denials of
  compression
bandages, garments and devices, which are medically
  required in the treatment of lymphedema.

Bob Weiss

Medical care's
  state of denial
Victoria Colliver, Chronicle Staff Writer

Monday,
June  23, 2008

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1


What to do if
you  are denied medical care

If your health insurance carrier is refusing
to  approve treatment recommended by your doctor, you have a
number
of  options. First, contact your health plan. You probably will have to go
through  the plan's internal
grievance process first. If time is of
the essence,  ask for an expedited review through the state.

Tips to help
you get the  care you need:


-- Review your health plan policy. Many
are available  online.

-- Make sure your doctor is aware of your problem.
Sometimes the  initial denial comes from the medical
group, which is
charged with  managing costs. In any case, your doctor's support is
important.

--  Request the reason for the denial in writing. Take
detailed notes of all  conversations, including the date
and time of
the call and the name of  the person you speak with. Save copies of all
paperwork, and keep
these  records in chronological order.

--
Act soon. If you wait longer than six  months, you could lose the right to file
a complaint, ask for an
independent medical review (also called an
IMR), or take other action  against your health plan such as
arbitration or a lawsuit. An IMR  decision is binding on the health
plan, but not the
  patient.
-------------------------------------------------------------------------------------------

NHIC
  Provider Education, Medicare Part B

Expiration of Therapy Cap
  Exceptions

The exceptions to outpatient therapy caps expire on June 30,
  2008.  Outpatient therapy service providers 
should not submit
claims  with the KX modifier for services furnished on or after July 1, 2008.  
To the 
extent possible, CMS is working with Congress, health care
providers,  and the beneficiary community to 
avoid disruption in
the delivery of  health care services and payment of outpatient physical
therapy, 
occupational therapy and speech-language pathology claims
for services  furnished by physicians, non- 
physician
practitioners, and therapists  paid under the physician fee schedule, beginning
July 1.   

For physical  therapy and speech language pathology services
combined, the limit on incurred  expenses  is
$1810.  For
occupational therapy services, the limit is  $1810.  Deductible and coinsurance
amounts 
applied to therapy services  count toward the amount
accrued before a cap is reached.   Therapy cap 
accruals began on
January 1, 2008, and some patients may have reached the  annual limits by June
30, 
2008.    

Providers may access the  accrued amount or
remaining amount of therapy services from the Medicare 
beneficiary
eligibility inquiry and response transactions.  Specifically:
o For CWF
users, the system returns the “appliedâ€� amount.  See CR4115 at 
http://www.cms.  hhs.
gov/transmit  tals/downloads/
/R759CP.pdf
o
For users of the HETS 270/271, the  system returns the “remainingâ€� amount.
See the page 18 of
the  270/271 user guide at  http://www.cms.  hhs.gov/HETSHelp
/Downloads/ HETS%20270-  271%
20User%20Compan  ion%20Guide. pdf
  
o
The Medicare contractors'  Interactive Voice Response units (IVR) return either
the remaining or  applied
amounts based upon contractor programming.
  For those few contractors  that do not provide  this
information on
their IVRs, providers can call  the contractors' customer service
representatives.   

For additional  information, Providers and Suppliers
should also read the Medicare Claims  Processing 
Manual, chapter 5,
section 10. 2 at    http://www.cms.  hhs.gov/manuals/
downloads/ clm104c05TXT. pdf

Patients Who
Have  Reached Their Limit(s) on Outpatient Therapy Services:
Note that
patients who  have reached their limit(s) on outpatient therapy services, other
than those who 
reside in a Medicare-certified part of a skilled
nursing facility, may  obtain medically necessary therapy 
services
that exceed the caps if  the services are furnished and billed by the outpatient
department of a 
hospital.  In other settings, outpatient therapy
services in excess of the  caps are not covered, and the 
therapy
provider may charge for those  services.  An Advance Beneficiary Notice is
recommended, but not 
required for services that exceed therapy
caps.

An ABN is available  at the following  link:   http://www.cms.
hhs.gov/BNI/ 02_ABNGABNL.
asp#TopOfPage  (click on ABN-CMS-R-131
Form).   In the box titled "Reason  Medicare will not pay"
the
following language is suggested Medicare  will not pay  more than $1810 for
expenses incurred for
physical  therapy and speech-language
pathology services  combined or for occupational  services in
2008.

Patients may be referred to this website for further
  information:
http://www.medicare
.gov/Publication  s/Pubs/pdf/ 10988.pdf
which will be activated by July 3,
  2008.

We will continue to be in communication with you with further
  information about payment of Medicare 
physician fee schedule
claims.  In addition, be on the alert for more information about other
legislative 
provisions which may affect you.

Reference:
JSM/TDL-08387; 
7/3/2008

----------------------------------------------------------------------------------

Extension
  of Therapy Cap Exceptions


July 16, 2008 

The Medicare
  Improvements for Patients and Providers Act of 2008 was enacted on July 15,
  2008.  One
provision of this legislation extends the effective date
of  the exceptions process to the therapy caps to
December 31, 2009.
  Outpatient therapy service providers may now resume submitting claims with the
  KX
modifier for therapy services that exceed the cap furnished on
or  after July 1, 2008.

For physical therapy and speech language
pathology  services combined, the limit on incurred expenses is
$1810 for calendar  year 2008.  For occupational therapy services, the
limit is $1810.  Deductible  and
coinsurance amounts applied to
therapy services count toward the  amount accrued before a cap is
reached.   Services that meet the  exceptions criteria and report the KX
modifier will be paid beyond this
limit.

Before this
legislation was enacted, outpatient therapy  service providers were previously
instructed to not
submit the KX  modifier on claims for services
furnished on or after July 1, 2008.  The  extension of the
therapy
cap exceptions is retroactive to July 1, 2008.   As a result, providers may have
already submitted
some claims without  the KX modifier that would
qualify for an exception.

Providers submitting  these claims using the
837 institutional electronic claim format or the UB-04  paper
claim
format would have had these claims rejected for exceeding  the cap.   These
providers should resubmit
these claims appending the  KX modifier so
they may now be processed and paid.  Providers submitting
these
claims using the 837 professional electronic claim format or the  CMS-1500 paper
claim format would
have had these claims denied for  exceeding the
cap.   These providers should request to have their claims
adjusted
in order to have the contractor pay the claim.  

In all  cases, if the
beneficiary was notified of their liability and the beneficiary  made payment
for services that
now qualify for exceptions, any such  payments
should be refunded to the
  beneficiary.
---------------------------------------------------------------------------------------

Seven
  Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup
  outlines missteps that can
be obstacles when applying for SSDI
  benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe
disabilities
know what it means to wait. They wait medical test results;  they wait
doctors’ diagnoses and
they wait for answers to their  questions
about the future. Delays are typical for people filing for Social
Security Disability Insurance (http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI)
  benefits,
but there are ways to avoid common mistakes that make the
  process even more difficult to navigate,
according to Allsup
  (http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St.
Louis,
Allsup represents people nationwide for their entitled SSDI
  benefits.Two-thirds of all SSDI applicants will
have their initial
  claim denied. If they appeal, and even if they are successful, they will go
  through several
additional steps and may wait two years or longer
  before they ev er see a disability payment. There are
some
missteps,  however, that can actually add time and increase the delay for an
SSDI award,  according to
Allsup.Social Security disability payments
are a  significant, and often the sole, income source for millions of
individuals
with disabilities and their families,said Edward Swierczek  (http://www.allsup.com/About-
Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx), senior
  claimant
representative with Allsup. Unfortunately, people with
  disabilities often make mistakes in applying for their
SSDI
benefits.  This may result in even more delays, which puts more stress on what
could  already be a
precarious financial situation.To help educate
claimants,  Allsup provides the following information on seven
common mistakes  people make when filing for SSDI benefits.Seven Common
Mistakes When Filing for
SSDI1. Going into the process uneducated.
Some people believe i's just  a matter of filling out a few forms,
sending them in and waiting for  their checks. They would be surprised
to find out just how complicated the
SSDI process really is. The
Social Security Administration follows a  five-step sequential evaluation
process
to determine if an individual  qualifies for disability
benefits (http://allsup.com/About-SSDI/Why-You-Want-
SSDI.aspx), explained
  Swierczek, including:*    You must not be gainfully employed, which is defined
  as
earning $940 a month or more, *    Your condition is severe,
meaning  it interferes with basic activities of
work, *    Your
condition is on  the Social Security Administration's list of disabling
conditions, or medically
equals one of the disabling conditions on
the list, and you will be  disabled for more than 12 months, *    You
are
not able to do the work  you had been doing before the impairment, and, *    You
can't perform any
other type of work. You have to meet the first two
criteria before the  Social Security Administration will
consider
your claim, said  Swierczek, who has more than 30 years of experience helping
individuals through
the complexities of the SSDI application process
(http://allsup.com/About-SSDI/SSDI-Process.aspx). If
you're a 40-year-old ironworker who hurt your back, the Social Security
  Administration may find that you
are not disabled if you can do
desk  work. You may not think you can, but if you don't provide compelling
evidence20why you can't, they will deny your claim, he said.2. Going
  through the SSDI process alone.
Individuals who apply for Social
  Security Disability Insurance benefits (http://www.allsup.com/About-
SSDI/Choosing-Representation.aspx) without
  representation are more likely to have their claim denied.
Working
with  government agencies and understanding the nuances of what's needed to
comply  with the
regulation isn't something the average person is
aware of,  said Allsup senior claimant representative David
Bueltemann  (http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup-
Experts/David-Bueltemann.aspx), who has
  successfully represented thousands of SSDI applicants.“Just
as
people  hire accountants to complete their tax returns and represent them before
the  Internal Revenue
Service if the're audited, individuals are
recognizing  they need representation when they go into the Social
Security  Disability Insurance process, he added.3. Underestimating the
impact of your  disability. Sometimes
pride leads people to
underplay the extent of  their disabilities because they have endured a
condition so long
that  they have learned how to cope with the
stress of daily life. But many people  underestima te how much
their
disability affects their day-to-day  lives. A good example, Bueltemann
explained, is a 50-year-old
grandmother who tells the state
Disability Determination Service (DDS) that  she takes care of her
grandchildren. If the woman doesn't explain that  the children are
teen-agers and self-sufficient, the DDS may
deny her  claim because
it believes that she is capable of working in a day care center.4.  Exaggerating
the
impact of your disability. On the other end of the  spectrum are
people who want to make their condition
appear worse than  it is.
For example, a man who uses a cane at a hearing before an administrative  law
judge
but does't normally use a cane would be over-representing his
  condition. “If the judge asks to look at the
cane and sees the
tip is  not worn, the claim is immediately suspect, even though the claimant may
have  had a
legitimate case if he’d just stuck to the
unexaggerated truth,  Swierczek explained. It is important to
elaborate, but not  exaggerate.â€�5. Being vague about your work
history. Knowing what the  expectations
are for your work, and
showing accurately from the outset  why you can't perform this work any longer,
is an
essential part of  qualifying for SSDI benefits
(http://www.allsup.com/About-SSDI/SSDI-Guidelines-by-
Disability.aspx). For example
,  Swierczek said, a service technician might be required to drive for extended

periods as part of the job.If your impairment means you can only
drive for  10 minutes without experiencing
extreme pain, yet your
job requires you  drive in 60-minute stretches, you need to make it clear on
your
disability application what the work expectations are and what
your  limitations are, said Swierczek.
Otherwise, you may end up in
double  jeopardy: Your disability claim is rejected because the Social Security

Administration believes you can still perform your work, he said.
But  you're out of work because you really
can't meet the
requirements of  the job.. Missing the appeals deadline. The Social Security
Administration
denies more than 60 percent of all initial SSDI
applications, but there is  a formal appeals process with three
levels. If you are rejected at any  level, you have only 60 days to
appeal to the next level. If you miss the
deadline, you need to
start the process from the beginning. If you've  applied on your own and
received a
denial, it's not too late to choose  an SSDI
representative (http://www.allsup.com/Allsup-
Representation/How-It-Works-At-Allsup.aspx), such as Allsup, to handle
the  appeal and continue with
your case. Taking this step may make
the  differenc e in experiencing further delays to receiving your SSDI
benefits.7.
Giving up. The process can be excruciatingly long and  cumbersome. Nearly
750,000 people are
waiting for a hearing before an  administrative
law judge, which is only one level of the SSDI appeals
process. For
individuals already facing significant physical or mental  disabilities, this
delay can add to the
difficulty. Bueltemann,  however, is quick to
point out that receiving SSDI is a benefit that individuals  with
disabilities and their families have earned, if they meet the SSDI
  requirements. An SSDI award also is
essential in securing other
forms  of financial support, including Medicare benefits (http://www.allsup.
com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and
retirement  protection.It may not be
as easy as it should be to
receive your  payments, but do not give up, Bueltemann said.Make sure you have

good  representation and don't lose hope that you can secure your
benefits.ABOUT  ALLSUPAllsup,
Belleville, Ill., is a leading
nationwide provider of  financial and healthcare related services to people with

disabilities.  Founded in 1984, Allsup has helped more than 100,000
people receive their  entitled Social
Security Disability Insurance
and Medicare benefits.  Allsup employs more than 500 professionals who
deliver
services  directly to consumers and their families, or through their employers
and  long-term disability
insurance carriers. For more information,
  visit
  www.Allsup.com.
Contacts:
Allsup - Rebecca Ray(800)  854-
1418, ext. 5065 Dan Allsup, ext.
  5760.
----------------------------------------------------------------------------------------


I
  have no idea if this is good or not, cause if the cap is 1810, my
therapy
for  less than 2 weeks 3 years ago was almost $9,000 so what
good is 1810?
Well I  hope this does help someone out there and that
it is a good
  thing.


If you are on Medicare and are provided lymphedema treatment
  by a Medicare-approved physical
therapist, you do not pay (except
for  deductables and 20% co-pay) for the service up to $1800. The
therapist  is not alowed to charge any more, and (s)he is reimbursed by
Medicare. The  reimbursement rates
vary from state to state, but run
about $25 per  unit, with 3-4 units per visit, that provides about 15-20
visits.

But  this annual limit has been suspended for many years by
Congress, but is now back  in place. But
Congress has also said that
in cases where there is a  medical necessity for more than the capped amount per

year, there would  be an exception process for certain conditions.
Last year lymphedema was on the  list of
exception conditions, so
the limit did not apply. But starting  July 1, the exception process
expired.

This new law just put the  exception process back. That's good,
since if you need more than 15-20
treatments in any one year for
your lymphedema, you can have them  justified.

I have no idea how your
therapist charged you $9,000 for a  course of lymphedema treatment. Did that
cost
include bandages or  garments (not covered by
Medicare)?

Bob Weiss
Lymphedema Patient
  Advocate

-----------------------------------------------------------------------------------

Bob...
  I just got a new prescription for Compression hose... I have never worn any...
I  just can't afford them
right now.. I had one RX but did not even
try to  get them because I knew that I could not afford them.. I am
on  Medicaid.. should I try with this RX and then when I get turned down
then try  the appeals process or
should I wait until I can afford a
pair and then  try and after I have to pay for them go for an appeal? I really

just  can't afford them.. I can't afford my treatment at all.. so I
am just waiting in  limbo right now... It is a little
hard to do
when I get fluid in my  knees and can't stand up on my own at times... any
advice???? Thanks,
Marbeth :)


Marbeth,

Find a
Medicare approved supplier and  give them a copy (you keep the original) of the
doctor's prescrition
and ask them to request an advanced approval to
Medicaid and to Medicare if  you are on both. It will be
denied, but
you will then have something to  appeal and a claim number that can be tracked.
The prescription
should  clearly state that the stocking is
necessary to treat your lymphedema, with the  appropriate diagnostic
code.

Bob
  Weiss

----------------------------------------------------------------------------------

By
  accepting the denial of treatment or a compression garment on the basis of the
  the letter of denial which
says it is not covered, we allow this
  insurance travesty to continue. Appeal each and every denial of
lymphedema treatment. If you run into what appears to be a brick wall
  contact me and I'll see how to
approach an appeal.

Bob
  Weiss
Lymphedema Treament
  Advocate
=================================================================

San
  Francisco Chronicle Examines Health Insurance Claim Denials

The San
  Francisco Chronicle on Monday examined how "[e]ach year, thousands of
  Californians find
themselves at odds with their health insurers
over  whether they, as patients, should get the treatment their
doctors  prescribed."

Insurers say that physicians do not always
prescribe the  most cost-effective treatments. Anthem Blue Cross
says it follows  strict protocols in denying care and relies on medical
evidence to determine  what care is
appropriate. Michael Belman,
Anthem's medical director,  said, "Even in a dire situation, it is ethically
appropriate to  withhold treatment if it's not effective." Alan Sokolow,
chief medical officer  for Blue Shield of
California, said, "We
think that is our job -- to  help patients and providers apply the benefit
package the
patient has,  the dollars they put for insurance
coverage and health care, in the most  appropriate and effective
way," adding that patients should appeal  denials if they
disagree.

According to the Chronicle, in 2007, the  state's HMO Help
Center received about 90,000 calls from
individuals  with health
insurance disputes. The majority of disputes involved whether  treatment or
procedures prescribed by physicians were "medically  necessary" or
considered "experimental" or
"investigational." The state
  Department of Insurance, which regulates a smaller number of insurance plans,

received 35,280 complaints and resolved 262 independent medical
review  cases in 2007. The Department
of Managed Health Care since
2001 has  offered third-party medical reviews and has resolved 1,716 IMRs
since  2007. According to DMHC, roughly 40% of decisions are settled in
favor of the  patient.

Jerry Flanagan, health advocate for Consumer
Watchdog, said that  issues arise because health insurers "are
going
back to the old  strategies of the '90s, when they interrupted care on the front
end by denying  or
delaying treatment offered by a doctor." He said
insurers hope  patients will not dispute the decisions or
settle for
less, in order to  save money -- a statement that insurers dispute.

The
Chronicle also  profiled the cases of three individuals whose claims were denied
by insurers  (Colliver,
San Francisco Chronicle,
  6/23).


------------------------------------------------------------------------------

see
  link to upcoming CMS public meeting agenda regarding Durable
  Med
http://www.cms.  hhs.gov/MedHCPCS
GenInfo/Download s/HCPCS_Meeting_ Agenda_DME_ 052808.
pdf

SEE page 11
  --
topic 08.71

Garments to be discussed : FLEXITOUCH.

We need
  to continue to contact our local politicians to continue to push for
all
  lymphedema garments expenses to be covered!
Thanks Lisa for the
  heads-up.

This request is for Medicare Codes for the body garments used
  with the Flexitouch pneumatic compression
controller. They are
coded as  "durable medical equipment" since they are used in conjunction with a
piece of
durable medical equipment. This ruling will in no way
affect coverage  of compression bandages or garments,
which are a
different Medicare  benefit category (i.e. "prosthetic devices").

I'm
afraid that while  contacting our local politicians serves a valuable
educational function, it will  not achieve
coverage without either a
new law or by forcing CMS to  re-interpret the current law. And to do the
latter,
there must be a  ground-swell of appeals from lymphedema
patients who are denied coverage for  their
garments.

I will
make this offer: If you file a claim for  the garments or bandaging kits that
you paid for in the last couple
of  months, when the denial comes
from your insurance company or from Medicare, I  will help you file the
three appeals necessary to reach an  Administrative Law Judge. At this
point you have a good chance of
being  reimbursed. I do not charge
for this help. I'm trying to get favorable decisions  from as many different
ALJs as I can. Then I will confront CMS for a  change in their
interpretation of the Social Security Act.

I will also  help your
Congressional representative draft and introduce a bill to change  Medicare, if
you can
interest him or her in your cause.

Robert  Weiss,
M.S.
Lymphedema Treatment Advocate
National Lymphedema
  Network

-------------------------------------------------------------------

There
  have been recent "clarifications" to the "incident to" physician services rules
  which may impact
provision of therapy services for some lymphedema
  therapists. The changes to the policies are summarized
  in

http://www.cms.  hhs.gov/MLNMatte
rsArticles/ downloads/  MM5288.pdf

with the full-text policy revisions
  given in

http://www.cms.  hhs.gov/Transmit
tals/downloads/ R87BP.pdf

-------------------------------------------------------------------------------------------

Settlement
  to Ease Drug Costs for Some on Medicare

By ROBERT
  PEAR
http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin
Published:
  June 20, 2008
WASHINGTON - The Bush administration promised on Thursday to
  provide new
protections for low-income Medicare beneficiaries to ensure they
  can get
prescription drugs promptly, at minimal cost.

The promise
came  in the proposed settlement of a nationwide class-action lawsuit
filed
on  behalf of hundreds of thousands of people who have had difficulty
getting
the  medicines they need.

Under the 2003 Medicare law, more than six
million  people eligible for both
Medicare and Medicaid are entitled to extra
help  with their drug costs. But in
many cases, they could not get the
assistance,  so they did not receive the drugs
they needed, or they
experienced long  delays.

In early 2006, low-income beneficiaries were
often overcharged,  and some were
turned away from pharmacies without getting
their medications.  Several states
declared public health emergencies, and
many stepped in to pay  for prescriptions
that should have been covered by
the federal Medicare  program.

Under the proposed settlement, filed
Thursday with the United  States District
Court in San Francisco, federal
Medicare officials promised  to speed up the
process of providing extra help
to low-income people, who now  could qualify
within days, rather than weeks
or months.

Drug benefits  are delivered by private insurers under
contract to Medicare.
Under the  settlement, these insurers will have to
provide medications at minimal
cost  for any Medicare recipients who prove
they have low incomes and qualify  for
extra help.

For most people
with incomes less than the poverty  level ($10,400 a year for an
individual),
the maximum co-payment is $1.05 for  a generic or preferred
brand-name drug
and $3.10 for other prescription  drugs.

But many beneficiaries have been
asked to pay much higher amounts,  from $30 to
$75 or more, because the
evidence of their low-income status was  not properly
shared among federal
and state agencies, insurance companies and  pharmacies.

"This settlement
agreement is a victory for many of the  nation's most vulnerable
citizens,
who have faced life-threatening delays in  obtaining vital
medications," said
Kevin Prindiville, a lawyer at the  National Senior Citizens
Law Center,
which filed the lawsuit with another  nonprofit group, the Center
for
Medicare Advocacy.

Gill Deford, a  lawyer at the Center for
Medicare Advocacy, said the settlement
would "help  hundreds of thousands of
people a year get their prescription drugs
more  quickly, at nominal
cost."

Jeff Nelligan, a spokesman for the federal  Centers for Medicare
and Medicaid
Services, said federal officials had  "worked tirelessly" to
ensure that Medicare
recipients could fill their  prescriptions. He refused
to comment on the
substance of the settlement,  noting that it was subject to
approval by Judge
Thelton E. Henderson of  Federal District Court in
California.

States administer the Medicaid  program. They have crucial
information showing
whether Medicare beneficiaries  are also enrolled in
Medicaid and therefore
eligible for extra help with  their drug
costs.

Under the settlement, if a beneficiary claims to be  eligible for
the low-income
subsidy but does not have the documents to prove  it, and if
the person is about
to run out of a medication, federal officials  would
immediately contact the
state Medicaid agency to check whether the  person
had been on
  Medicaid.

--------------------------------------------------------------------------------

News
  from New York State
Assemblyman ALAN N. MAISEL
59th ASSEMBLY
  DISTRICT

Date: June 23, 2008 


Assembly Passes Maisel Measure
  To
Raise Awareness of Lymphedema



Today, in Albany,
Assemblyman  Alan Maisel (D-Kings County) announced passage in the Assembly of

legislation to promote lymphedema and lymphatic disease reporting
and  awareness (A05892B). TThe
measure requires health care
providers, who  are already required to report cases of cancer or oother
malignant  disease, to also report instances of lymphedema related to
cancer treatment in  their patients. This
legislation also requires
the Department of Health  to develop a health care and wellness education and

outreach program  for those seeking information on either primary or
secondary  lymphedema.

"Lymphedema is not a high profile disease like
cancer or  diabetes that generates a lot of press or mmoney
for
research, yet it  affects an estimated six million men, women and children in
the United States,"  stated
Maisel. "The lymphatic system is vital
to the health of every  individual as it is an integral part of tthe immune
system.� Lymphedema is an accumulation of lymphatic fluid that causes
painful,  disfiguring sswelling,
usually in the arms or legs. There
are two major  types of lymphedema: primary (congenital) and ssecondary
(caused by  tissue injury, scarring, lymph node removal, or
infection).

"The largest  group of people who acquire secondary
lymphedema arc cancer patients, including  those with
breast,
prostate, lung, and melanoma patients," stated  Maisel. "This bill helps to
ensure that when
lymphedema is acquired  from the life-saving cancer
treatments, these instances of disease are also  rreported
to the
cancer registry. This will help raise awareness of the  disease and hopefully
increase the mmoney
raised to fund additional  research to help find
the cause of and cure for lymphatic diseases, lymphedema,
and
related disorders."

"It amazes me that despite the essential  role the
lymphatic system plays in human health, awareness,
education  and
research have been relatively neglected," stated Maisel. "This lack of focus
  has created
barriers to effective delivery of health care and
public  education about these diseases, its diagnosis,
treatment,
therapy and  long-term care. This legislation, which is on third reading in the
Senate, is  just the first
step in raising public awareness about
  lymphedema."


--------------------------------------------------------------------------------------------
UNINSURED
  STATS:

At its best, the United States health care system is second to
  none. It is quick to adopt and diffuse new
technologies.1 It scores
  best in the world for patient participation in treatment decisions, respect for

confidentiality, provision of prompt care, respect for patients, and
  clean surroundings.2 But despite having
the highest health care
  spending per capita, the U.S. consistently scores at or near the bottom in
comparisons with other developed, high income countries on infant
  mortality, life expectancy, and the
proportion of the population
with  health insurance coverage (OECD, 2002, WHO, 2000). Almost everyone
in  these countries has coverage. In the U.S., by contrast, 15.3 percent
of the  population - or 44.8 million
people – were uninsured in
2005.3 What are  the consequences of 36.7 million adults and 8.1 million
children living  without health insurance coverage?

In a sweeping
6-volume series on the  consequences of uninsurance, the Institute of Medicine
reported the
following conclusions:

Compared to people with
insurance, uninsured  children and adults experience worse health and die
sooner.
Families can  suffer emotionally and financially when even a single
member is  uninsured.
"Uninsurance at the community level is associated with
financial  instability for health care providers and
institutions,
reduced  hospital services and capacity, and significant cuts in public health
programs,  which may
diminish access to certain types of care for
all residents,  even those who have coverage."4
The nation as a whole is
economically  disadvantaged as a result of the poorer health and premature death
of
uninsured Americans. The IOM estimated that the lost economic
value of  uninsurance is between $65 billion
and $130 billion
  annually.5

--------------------------------------------------------------------------------

Sources

1Docteur,
  Elizabeth, Hannes Suppanz, and Jaejoon Woo. 2003. The US Health System: An
  Assessment
and Prospective Directions for Reform. Economics
Department  Working papers No. 350. Accessed May
28, 2004. Available
at  www.oedc.org/eco.

2Findings based on surveys conducted in 35
countries.  World Health Organization. 2000. The World
Health Report
2000—Health  Systems: Improving Performance. Geneva,
Switerland.

3Employee Benefit  Research Institute estimates from the
March Current Population Survey, 2006
Supplement.

4Institute
of Medicine. 2004. Insuring America's Health.  Washington, DC: National Academy
Press, p. xi

5Institute of Medicine.  2004. Insuring America’s Health.
Washington, DC: National Academy Press, p.  xi.
Coverage Matters for
Individuals

Public opinion on this question  has shifted overtime; but in
1993, when health care was at the top of the
national political
agenda, fully 43 percent of Americans agreed with the  statement that uninsured
people are
"able to get the care they need  from doctors and
hospitals."1 And just 7 years ago, in 1999, a majority (57
percent)
of Americans held this view. Clearly, there is a commonly held  belief in this
country that uninsured
Americans get the health care  they need.2
However, available evidence shows that this belief is clearly
  false.

Adults

In their landmark study of the consequences of
  uninsurance,3 the Institute of Medicine concluded that
"adults
without  coverage do not get the care they need and are more likely to suffer
poor health  and
premature death than are insured adults." A more
recent study also  found that the uninsured receive less
care than
the insured and  experience poorer outcomes.4

Long-term studies indicate
that, compared to  insured adults, uninsured adults have a 25 percent greater
risk
of  premature death. This mortality difference exists after
social, demographic,  health status and health
behavior differences
are statistically  removed.5
The Institute of Medicine estimates that the
number of excess  deaths each year among uninsured adults, age
25-64, is 18,000.6 By way  of comparison, consider the number of
estimated annual deaths in the under age
65 population due to the
following causes:

- Diabetes:  17,500
- Stroke: 19,000
- HIV/AIDS:
14,100
- Homicide  19,7007
Preventive Care

Uninsured adults are
less likely to receive  recommended preventive and screening services than
insured
adults. This  includes:
- Pap tests for cervical cancer
in women,
- Clinical breast  exams and mammography in women,
- Fecal
occult blood tests for colorectal  cancer,
- Sigmoidoscopies for colorectal
cancer,
- Blood pressure checks  for hypertension, and
- Cholesterol
tests.8


Compared to adults  with insurance, when uninsured adults
receive screening services, they are less  likely to
receive them on
a timely basis.9
Because they lack timely  access to screening services,
uninsured adults with cancer (breast, colon,  prostate)
tend to have
poorer outcomes and are more likely to die  prematurely than adult cancer
patients with
insurance. Poor access to  screening services results
in delayed diagnosis; and survival probability is a
function of the
stage of the cancer at diagnosis.10
The longer  adults under age 65 are
without health insurance, the less likely they are to  receive preventive
services.11
Health insurance coverage increases  access to and use of
preventive services, but it does not erase
disparities in the use of
these services among racial groups.12
Chronic  Care

Chronic
conditions—including cardiovascular disease, diabetes,  terminal kidney disease,
HIV infection, and
mental illness—are the  leading cause of death,
disability, and illness in the United  States.13

Uninsured adults with
cardiovascular disease receive fewer  professionally recommended services and

experience worse health  outcomes than insured adults with
cardiovascular disease. They are less likely  to:
- be screened for
hypertension and high cholesterol,14
- have their  blood pressure monitored
frequently,15 and
- stay on drug therapy for
  hypertension.16


Diabetes requires intensive care management, but
  non-elderly adult diabetics are almost as likely to be
uninsured as
  non-elderly adults in general.17
- Compared to insured non-elderly adults
  with diabetes, uninsured diabetics are less likely to receive
appropriate standards of care, which can lead to uncontrolled blood
sugar  levels, greater risk of
hospitalization, and increased risk
of  additional chronic disease and disability.18
- Among non-elderly adult
  diabetics, lack of insurance is associated with less glucose monitoring and
  fewer
foot and eye exams. These services are professionally
recommended  disease management strategies.19


Compared to insured
non-elderly  adults, those without insurance
- who have end-stage renal
disease are more  likely to begin dialysis once the disease has progressed to a

more  advanced stage, which has a negative effect on health
outcomes.20
- who have  HIV infection are less likely to receive the most
effective drugs, are more  likely to fail to receive
needed care21 ,
and have a higher risk of  mortality.22


Compared to insured adults
with behavioral health  coverage, uninsured adults are less likely to receive

mental health  services consistent with recommended treatment
guidelines.23 Uninsured adults  with severe
mental illness are much
less likely to use specialty mental  health services than publicly insured
persons. 24
Pregnant Women and  Children

After conducting an
exhaustive review of the literature, the  Institute of Medicine concluded that
"[h]aving
health insurance  increases the chances that infants,
children, and pregnant women will receive  preventive
services when
well, and timely medical care when sick or at  high risk of poor outcomes.
These, in turn, help
avoid unnecessary  hospitalizations, premature
births, extended morbidity, or even  death."25

The IOM was careful to
note, however, that "[a]lthough having  insurance makes a difference, simply
making
insurance available may not  be enough to improve health care
and health outcomes for all of the uninsured.
Some high-risk groups
may require additional services (e.g.,  educational interventions, targeted case

management) if they are to  obtain good preventive and routine
care."26

Pregnant  Women

Uninsured pregnant women use fewer
prenatal services than publicly  or privately insured pregnant women.
In
one study, the rate of unmet  needs reported by uninsured women (18 percent) was
more than twice that
of insured women.27
Pregnant women without
health insurance are less  likely to receive expensive maternity and neonatal

services. For  example, the caesarian section rate for uninsured
women is lower than the rate  for insured
women. Although it is
believed by some that c-section is an  overused procedure, a study that examined

insurance status differences  in c-section rates when it was an
appropriate procedure (in cases of breech
presentation or fetal
distress) found lower use rates among uninsured  women.28
Medicaid expansions
during the late 1980s brought public coverage to  many previously uninsured
women.
Although the evidence is mixed, some  studies show
significant population-level changes in the use of prenatal
services
following Medicaid expansion.29

Children

Uninsured  children have
less access to health care providers and use health services less  frequently
than
children with private or public insurance.30
When
  previously uninsured children are enrolled in public insurance programs, they
  use more health services
and use health services more
  appropriately.31
Multiple factors hinder children's access to, and use of,
  health services, including low income, immigrant
status, and
certain  race/ethnicity categories. Because 40 percent of children in one of
these groups  are in at
least one other, the barriers to health care
access and use  are compounded for many children.32
Although having insurance
coverage  improves access to and use of care for children, other important
factors
include "poverty, diet, exercise, smoking, and other
behavioral
  factors."33


--------------------------------------------------------------------------------

Sources

1Blendon
  et al., 1999, p. 207 (IOM, p 21, bottom)

2Institute of Medicine (IOM).
  2001. Coverage Matters. Insurance and Health Care. Washington, DC:
National Academy Press, p. 21.

3Institute of Medicine (IOM).
2001.  Coverage Matters. Insurance and Health Care. Washington, DC:
National  Academy Press; Institute of Medicine (IOM), 2002. Care Without
Coverage. Too  Little, Too
Late. Washington, DC: National Academy
Press; Institute of  Medicine (IOM). 2002. Health Insurance is a
Family Matter. Washington,  DC: National Academy Press; Institute of
Medicine (IOM). 2003. A Shared
Destiny. Community Effects of
Uninsurance. Washington, DC: National Academy  Press; Institute of
Medicine (IOM). 2003. Hidden Costs, Value Lost.  Uninsurance in America.
Washington, DC: National
Academy  Press

4Hadley, Jack, 2007.
"Insurance Coverage, Medical Care Use, and  Short-term Health Changes Following

an Unintentional Injury or the  Onset of a Chronic Condition,"
Journal of the American Medical Association
297:1073-1084.5Franks,
Peter; Carolyn Clancy, and Marthe Gold. 1993. Health  Insurance and Mortality.

Evidence from a National Cohort. Journal of  the American Medical
Association 27(6):737-741.

5Franks, Peter; Carolyn  Clancy, and Marthe
Gold. 1993. Health Insurance and Mortality. Evidence from a
National
Cohort. Journal of the American Medical Association
  27(6):737-741.

6Institute of Medicine (IOM), 2002. Care Without
Coverage.  Too Little, Too Late. Washington, DC:
National Academy
Press pp.  161-165 and Table D.1.

7Institute of Medicine (IOM). 2004.
Insuring  America's Health. The National Academies Press,
Washington, D.C., p.  46.

8For multiple sources, see Institute of
Medicine (IOM), 2002. Care  Without Coverage. Too Little, Too
Late.
Washington, DC: National  Academy Press, pp. 47-51.

9Institute of
Medicine (IOM), 2002. Care  Without Coverage. Too Little, Too Late. Washington,
DC:
National  Academy Press, p. 48.

10Institute of Medicine
(IOM), 2002. Care Without  Coverage. Too Little, Too Late. Washington, DC:
National Academy Press,  pp. 52-57.

11Ayanian, John, Joel
Weissman, Eric Schneider, Jack Ginsburg,  et al. 2000. Unmet Health Needs of
Uninsured Adults in the United  States. Journal of the American Medical
Association  284(16):2061-2069.

12Has, Jennifer and Nancy Adler. 2001.
The Causes of  Vulnerability: Disentangling the Effects of Race,
Socioeconomic Status  and Insurance Coverage on Health. Background paper
prepared for the Committee
on the Consequences of
Uninsurance.

13Centers for Disease  Control and Prevention (CDC). 2000.
"Chronic Disease Prevention: Heart Disease
and Health Promotion."
Web page, not accessible on April 13, 2004, but  see other performance plans at

www.cdc.gov/od/perfplan/

14Ayanian, John, Joel Weissman, Eric
  Schneider, Jack Ginsburg, et al. 2000. Unmet Health Needs of
Uninsured  Adults in the United States. Journal of the American Medical
Association  284(16):2061-2069.

15Fish-Parcham, Cheryl. 2001. Getting
Less Care: The  Uninsured with Chronic Health Conditions.
Washington, DC: Families USA  Foundation.

16Huttin, Christine,
John Moeller, and Randall Stafford.  2000. Patterns and Costs for Hypertension

Treatment in the United  States. Clinical Drug Investigation
20(3):181-195; Fish-Parcham, Cheryl. 2001.
Getting Less Care: The
Uninsured with Chronic Health Conditions.  Washington, DC: Families USA
Foundation.2001

17Harris, Maureen.  1999. Racial and Ethnic
Differences in Health Insurance Coverage for Adults with
Diabetes.
Diabetes Care 22(10):1679-1682.

18Palta, Mari, Tamara  LeCaire, Kathleen
Daniels, Guanghong Shen, et al. 1997. Risk Factors for
Hospitalization in a Cohort with Type 1 Diabetes. American Journal of
  Epidemiology 146(8):627-636.

19Beckles, Gloria, Michael Engelgau, KM
  Venkat Narayan, William Herman, et al 1998. Population-
Based
Assessment  of the Level of Care Among Adults with Diabetes in the U.S. Diabetes
Care  21(9):1432-
1438.

20Obrador, Gregorio, Robin Ruthazer,
Arora  Pradeep, Annamaria Kausz, et al. 1999. Prevalence of and
Factors  Associated with Suboptimal Care Before Initiation of Dialysis
in the United  States. Journal of the
American Society of Nephrology
10(8):1793-1800.;  Kausz, Annamaria T., Gregorio T. Obrador, Pradeep
Arora, Robin  Ruthazer, et al. 2000. Late Initiation Dialysis Among
Women and Ethnic  Minorities in the
United States. Journal of the
American Society of  Nephrology 11(12):2351-2357.

21Cunningham, William
E., Ron D. Hays, Kevin  W. Williams, Keith C. Beck, et al. 1995. Access to
Medical Care and  Health-Related Quality of Life for Low-Income Persons
with Symptomatic Human
Immunodeficiency Virus. Medical Care
33(7):739-754; Cunningham, William E.,  Ronald M. Andersen,
Mitchell
H. Katz, Michael D. Stein, et al. 1999.  The Impact of Competing Subsistence
Needs and Barriers
on Access to  Medical Care for Persons with Human
Immunodeficiency Virus Receiving Care in the  United
States. Medical
Care. 37(12):1270-1281; Katz, Mitchell H.,  Sophia W. Chang, Susan P.
Buchbinder,
Nancy A Hessol, et al. 1995.  Health Insurance and Use
of Medical Services by Men Infected with HIV.
Journal of Acquired
Immune Deficiency Syndrome and Human Retrovirology.  8(1):59-63; Shapiro, Martin

F., Sally C. Morton, Daniel F. McCaffrey,  J. Walton Senterfitt, et
al. 1999. Variations in the Care of HIV-
Infected Adults in the
United States. Journal of the American Medical  Association 281(24):
2305-2315.

22Goldman, Dana P., Jayanta Bhattcharya,  Daniel F. McCaffrey,
Naihua Duan, et al. 2001. Effect of
Insurance on  Mortality in an
HIV-Positive Population in Care. Journal of the American  Statistical
Association
96(455): 833-894.

23Cooper-Patrick,  Lisa, Rosa M. Crum, Laura A. Pratt,
William W. Eaton, et al. 1999. The  Psychiatric
Profile of Patients
with Chronic Disease Who Do Not Receive  Regular Medical Care. International
Journal
of Psychiatry 29(2):  165-180; Sturm, Roland, and Kenneth B.
Wells. 1995. How Can Care for Depression
Become More Cost-Effective?
Journal of the American Medical Association  273(1): 51-58.

24McAlpine,
Donna D., and David Mechanic. 2000.  Utilization of Specialty Mental Health Care
Among
Persons with Severe  Mental Illness: The Roles of
Demographics, Need, Insurance, and Risk. Health
Services Research
35(1): 277-282.

25Institute of Medicine, 2002.  Health Insurance is a
Family Matter. The National Academies Press,
Washington, D.C., pp.
136-7.

26Institute of Medicine, 2002. Health  Insurance is a Family
Matter. The National Academies Press,
Washington,  D.C., p.
139.

27Bernstein, Amy. 1999. Insurance Status and Use of Health  Services
by Pregnant Women. Washington,
DC: March of
  Dimes.

28Stafford, Randall. 1990. Cesarean Section Use and Source of
  Payment: An Analysis of California
Hospital Discharge Abstracts.
  American Journal of Public Health 80(3):313-315.

29Institute of Medicine
  (IOM). 2002. Health Insurance is a Family Matter. Washington, DC: National
Academy Press, pp.128-130.

30Institute of Medicine (IOM). 2002.
  Health Insurance is a Family Matter. Washington, DC: National
Academy  Press, pp. 111ff.

31Currie, Janet and Jonathan Gruber.
1996. Health  Insurance Eligibility, Utilization of Medical Care and
Child Health.  Quarterly Journal of Economics 111(2):431-466; Szilagyi,
Peter, Jack Zwanger,  Lance
Rodewald, Jane Holl, et al. 2000.
Evaluation of a State Health  Insurance Program for Low-Income
Children: Implications for State Child  Health Insurance Programs.
Pediatrics 105(2): 363-371; Lave, Judy,
Christopher Keane,
Chyongchiou Lin, Edmund Ricci, et al. 1998. Impact of a  Children's Health
Insurance
Program on Newly Enrolled Children. Journal  of the
American Medical Association 279(22):1820-1825.

32Newacheck, Paul,  Dana
Hughes, and Jeffery Stoddard. 1996. Children's Access to Primary Care:
Differences
by Race, Income, and Insurance. Pediatrics 97(1):  26-32.

33Institute of
Medicine (IOM). 2002. Health Insurance is a Family  Matter. Washington, DC:
National
Academy Press, pp.IOM, 2:9  top.
Health care spending in
the United States has grown rapidly since the  1960s, at an average rate of 10

percent a year.

In 2005, nearly  $2 trillion was spent on
health care in the United States. The amount of money  spent on
health care is expected to increase to $4.1 trillion by
  2016.1
Spending on health care accounted for about 16 percent of Gross
  Domestic Product (GDP). By 2016, the
Center for Medicare and
Medicaid  Services (CMS) projects that health care will account for about 20
percent of GDP.2
While health care spending has been increasing, the
  distribution of health care spending among different
services has
been  changing.

Since the 1980s, the percentage of health care spending
for  hospital care has declined. In 1980, hospital
care accounted
for 40  percent of all health care spending. By 2004, it accounted for 30
percent, and  is
expected to remain at roughly 31 percent between
now and  2016.3
By contrast, the share of spending for physician and other
  professional services rose over the same time
period, from 27
percent  of in 1980 to 28 percent in 2005. It is expected to fall slightly to 26
percent  through
2016.4
The share of health care spending
accounted for by  prescription drugs increased from 5 percent in 1980 to
10 percent in  2005, and is expected to reach 12 percent in
2016.5

The cost of providing  health care services has been increasing
faster than the Gross Domestic Product
(GDP) since 1998, but the gap
between the two declined recently as the  economy recovered from
recession and health care costs grew more  slowly.

During 2001,
health care costs increased 11.3 percent, while GDP  increased by only 2.1
percent. By 2006,
health care costs increased 7.7  percent, compared
to 5.9 percent GDP growth.7

Recent spending on health  care services has
slowed for all categories of health care, but cost increases  for
hospital outpatient services and prescription drugs continue to  outpace
those for inpatient and physician
services.
Sources

1Employee Benefit Research Institute
estimates  from Centers for Medicare and Medicaid Services and U.
S.
Department of  Commerce.

2Employee Benefit Research Institute estimates
from Centers for  Medicare and Medicaid Services and U.
S. Department
of  Commerce.

3Employee Benefit Research Institute estimates from Centers
for  Medicare and Medicaid Services.

4Employee Benefit Research Institute
  estimates from Centers for Medicare and Medicaid Services.

5Employee
  Benefit Research Institute estimates from Centers for Medicare and Medicaid
  Services.

6Employee Benefit Research Institute estimates from Centers
for  Medicare and Medicaid Services.

7Strunk, Bradley C., Paul B.
Ginsburg,  and John P. Cookson. "Tracking Health Care Costs: Declining
Growth
  Trend Pauses In 2004." Health Affairs Web Exclusive, June 21, 2005; and
  Ginsburg, Paul B.,
Bradley C. Strunk, Michelle I. Banker, and John
P.  Cookson. "Tracking Health Care Costs: Continued
Stability But At
High  Rates In 2005.." Health Affairs Web Exclusive, Oct. 3,
  2006.

=================================================================

The
  Office of the Medicare Beneficiary Ombudsman was set up to help Medicare
  Beneficiaries with their
problems with Medicare. The MBO web page
  is
  http://www.cms.hhs.gov/center/ombudsman.asp



The following
are  some important links to resources in and outside this
  organization:

Office of the Medicare Beneficiary Ombudsman

•    
http://www.medicare.gov/Publications/Pubs/pdf/11173.pdf
•    
http://www.cms.hhs.gov/OpenDoorForums/downloads/Ombudsman0506ReporttoCongress.pdf
 


•     Contact Us - If you have an issue that requires a response,
  please contact 1-800-MEDICARE.  If your
inquiry requires a response
  from the Medicare Ombudsman, 1-800-MEDICARE will direct your inquiry

to
  the Medicare Ombudsman.



Resources for Assistance with Medicare
  Issues

•  

http://www.medicare.gov/CallCenter.asp
- Get general
  information about MEDICARE. 

•    http://www.medicare.gov/Ombudsman/resources.asp- Provides
  information regarding how to file an
inquiry, complaint, grievance,
or  appeal across different areas of Medicare.


Other Helpful
  Resources

•     http://www.medicare.gov/contacts/Static/RelatedWebsites.asp- Allows you
to  access other websites
that can provide additional help or
information  that is not presented in www.medicare.gov.
•    
http://www.hhs.gov/od/
-
The Office of Disability oversees  the implementation and coordination of
disability programs, policies  and special initiatives for persons with
disabilities.
•     http://www.aoa.gov/eldfam/eldfam.asp- The
  Administration on Aging provides home and community-
based services
and  opportunities to older persons and their caregivers through programs funded
  under the
Older

Americans Act.
•   http://www.cms.hhs.gov/home/medicaid.asp - If you
can't  pay for your medical expenses right now, this
is the place to
find  information on assistance that may be
  available.

=================================================================
HOW
  TO GET THE BEST CARE IN MEDICAL FACILITIES

This message is off topic,
but  posted here because it is something that
is likely to affect almost
everyone  at one time or another.  This
information may be helpful to prevent
  unnecessary illness or suffering,
and may even save a life.

The
  material came from a list that discusses health care insurance issues
and
  policies, and managed care.  Most list members are either physicians
or
  lawyers.  The owner of the list is both, and is affiliated with UCLA.

I
  posted this information to another list, and several individuals
wondered
  about MRSA, one of the things discussed in the article.  To
avoid confusion,
  the material I posted in response to the inquiries is
also posted
  here.

The reason for this post is to advise the public, regarding use
  of
advocates to assist patients in hospitals, nursing homes, and other
  such
similar residential medical institutions to obtain proper assistance
  when
someone is in a medical facility, and to prevent injuries and death. 
It
was never meant to constitute medical advice.  Information about this
  (or
any other medical) condition, how to diagnose it, treat it, or prevent
  it
should be discussed with medical providers, not this list.

This is
  posted for educational purposes only.  It does not constitute
medical or
  legal advice.

Any questions regarding this material should be directed
to  undersigned
poster, at
X1234567890@Juno.Com
subject:
HEALTH  CARE FACILITIES
************************
Bedside Manner:
Advocating for a  Relative in the Hospital

By MELINDA BECK

Don't
go to the hospital  alone, if you can possibly avoid it.

A friend of mine
slipped on the  sidewalk recently and broke her hip. She
had surgery in one
of the best  hospitals in the country.

But it was my friend's grown
daughter who  noticed that she was having an
adverse reaction to a pain
medication. And  that her IV drip had pulled
out of a vein and was pumping
her arm full of  fluid. And that the hot
compresses to reduce the swelling in
her arm had left  blisters on her
skin. And that the blood-sugar test she was
about to be given  was meant
for her roommate instead.

Having someone
with you in a  hospital who is alert and asking questions
can help stave off
all kinds of  potential problems, from mistaken
identity to medication mixups
to MRSA  infections. An estimated 100,000
hospital patients die every year in
the U.S.  because of preventable
errors. Many hospitals are under financial
pressures  to keep nursing
staffs lean. A personal advocate can be a valuable
resource.  It doesn't
have to be a relative -- and it can be more than one
person -- as  long as
they know you and are willing to speak up.

"If
we could make  only one change in health care, it should be to change
the
notion that  families are visitors. Families are allies and partners
for
safety and  quality," says Beverly Johnson, president of the
nonprofit
Institute for  Family-Centered Care, which is leading a movement
to
involve families  more.

A growing number of hospitals are doing
just that -- including  unlimited
visiting hours, letting family members
accompany patients to  procedures
and even stay during emergencies. "We're
drawing on the strength  of the
family. They're not out in the waiting room,
wondering what's going  on,"
says Pat Sodomka, senior vice president for
Patient and  Family-Centered
Care at MCG Health Inc., which runs a 630-bed
hospital in  Augusta, Ga.

Some hospitals now have nurses give
change-of-shift reports  at the
bedside and encourage families to share
observations.
"This is a  huge cultural change," says Mary Chatman, Chief
Nursing
Officer of Pitt  County Memorial Hospital in Greenville, N.C., which
is
giving family and  patient advisory groups a voice in designing
new
facilities and interviewing  physicians.

Initially, some staffers
worried that family involvement  would take up
valuable time, but in the long
run, it saves time because  doctors have
more information, says Ms. Chatman.
After MCG Health's  neuroscience unit
became more family-centered, average
length of stay dropped  50% because
discharge planning went faster. Patient
satisfaction rose, and  nursing
turnover dropped.

Still, it can be
difficult for family  members to know when to raise an
alarm and
how.

Karen Aydt Curtiss, a  market researcher in Lake Forest, Ill., often
felt
helpless while her  71-year-old father was recovering from a
lung
transplant in a big teaching  hospital in 2005. He was faring well
until
he fell, hit his head and was made  to lie flat until a neurologist
could
evaluate him. While he waited -- all  weekend -- his new lungs filled
up
with fluid. He developed pneumonia, then a  pulmonary embolism and
had
three MRSA infections. He died seven months after  the transplant,
having
never left the hospital.

"I wish I had grabbed  the neurologist
by the sleeve and dragged him to my
father's room," says Ms.  Curtiss, who is
writing a book on how to help a
loved one in the hospital,  titled "Someone
With You."

Among her suggestions:

- Ask everyone  who enters the
room if they've washed their hands and
sterilized equipment.  Use
antibacterial wipes on surfaces.

- Ask nurses to read drug orders  aloud
and make sure they match the
patient's ID bracelet. If it's a new
  medication, ask what it's for and
what to expect.

- Be alert for
  pressure wounds, also known as bedsores, particularly in
long hospital
stays.  Put a piece of sheepskin (available at
medical-supply stores) under  
 
the sheet to provide padding and cut moisture. Make sure patients
  are
moved often, and lifted, not slid, which can damage fragile
  tissue.

- Bring a deck of cards and other games to help patients work
  their minds
and motor skills.

- Keep a journal for observations --
  especially if you're sharing the
watch with others.

- Never give a
  patient medications on your own.

- Don't help a patient get in or out of
  bed by yourself.

- Be respectful and appreciative and remember that
other  patients may
have more urgent needs. But don't hesitate to speak up if
you  have
concerns. Says Ms. 
Sodomka: "You have knowledge that the
caregivers  just don't have."
==========================
Below is a very
basic  synopsis of the bacteria and how it functions, on a
very cursory
level.  It  is not intended to be taken as medical advice.

MRSA, which
stands for  Methacillian resistant Staphylococcus Aureus, is a
bacterial
infection that  can be contracted by direct contact with a
person who has
active MRSA, (or  sometimes, colonized MRSA) or by exposure
to droplets
emitted from such a  person, through coughing or sneezing.

MRSA is not
airborne, and N95  respirators are not required to protect
against infection
when visiting a  patient with this diagnosis.  However,
if that person also
has pneumonia,  which is very common among those
infected by MRSA, that is
airborne, and  droplet precautions and contact
precautions are not
sufficient.  In those  situations, it is prudent to
seek the advice of a
medical  professional.

Basically, MRSA, which is referred to by the CDC
and NIH as  USA300, is a
bacterium that destroys immune cells.

To
understand this  concept, a little basic background is needed
here.

Humans have a  reticuloendothelial system, or mononuclear
phagocytic
system, which basically  consists of a series of organs and cells
that
protect the human organism  against foreign invaders, such as
bacteria,
viruses and fungi.

White  blood cells, or leukocytes,
protect against particular invaders.
(White cells  also include Alpha, Beta
and Gamma Globulins, but these
generally protect  organs, and are not subject
of this issue).

There are three types of  leukocytes; granulocytes,
monocytes and
lymphocytes.  Lymphocytes are either  B cells, or T cells. 
Most have
heard of the T4 or CD4 which is the  lymphocyte that is affected
adversely
by HIV.

Monocytes produce the  macrophage cell, which
basically consumes dead
cells and tissue, and removes  it from the
body.

Granulocytes exist in three varieties; basophils,  neutrophils
and
eosinophils.  Neutrophils emit Cl [chlorine], H2O2 [hydrogen
  peroxide],
and an antimicrobial protein that normally destroys such
  invading
bacteria such as Staphylococcus, which is present in approximately
  30% of
the US population, either on their dermal layers, or in their
  mucosa.

Staphylococcus Aureus, however, recognizes the danger of the
  emissions
from the neutrophil, and rather than allowing itself to be
  destroyed by
it, it devours or consumes the neutrophil.  Thus, the
  expression, flesh
eating bacteria.

When staphylococcus Aureus is
  Methacillian resistant, it does not respond
to the broad spectrum
  antibiotics, such as Penicillins, Cephalosporins,
etc.  USA300 can also
  mutate to become Vancomycin resistant, wherein only
incision and debredment
  or amputation options remain.  If the bacterium
crosses the erythrocyte
  barrier, and is carried by the erythrocytes into
internal organs, death is
  likely.

That is the method by which MRSA destroys human tissue if left
  untreated.

Common treatments include incision and debredment, with
  antibiotics, or
the introduction of Vancomycin, a powerful gram specific
  antibiotic.

Two common types of MRSA have been identified.  HA-MRSA and
  CA-MRSA.
HA-MRSA is hospital acquired Methacillian resistant
  Staphylococcus
Aureus, and CA is community associated Methacillian
  resistant
Staphylococcus Aureus.



The official medicare
website  is located at :

http://www.medicare.gov/



How to find a
  prescription plan under medicare:

http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?
version=default&browser=IE%7C6%
7CWinXP&language=English&defaultstatus=0&pagelist=Home&View&PDPYear=2006&M
APDYear=2006&MPDPF%5FMPPF%5FIntegrate=N

From the looks
of  it there are 2 types of plans you can join:

Plans include HMOs, PPOs,
and  Private-Fee-for-Service plans. They offer complete Medicare-covered
health care, including drug coverage, through a single plan. Most of
these  plans generally offer extra benefits
and lower copayments
than the  Original Medicare Plan. However, you may have to see doctors that
belong
to the plan or go to certain hospitals to get
services.

FROM NORD  again:

Knowing Your Health History Could Save
Your Life

Most  Americans believe that knowing their family health
history can be beneficial,  but only about one-third
have actually
tried to gather and record  information about family health, according to a
recent study by the U.
S. Centers for Disease Control and Prevention
(CDC).

Furthermore,  the discussion of family history between physician
and patient typically lasts  just a few minutes.

"But knowing your family
history can save your life,"  US Surgeon General Richard H. Carmona said at a

press conference in  November to launch a project known as the
Family History Initiative. As part of  this
project, the Department
of Health and Human Services has created a  new computerized tool, called "My

Family Health Portrait," that can be  downloaded at
www.hhs.gov/familyhistory/ to help in the process.

Francis  S. Collins,
MD, PhD, director of the National Human Genome Research Institute,  noted that
all
people have genetic abnormalities that make them more
  susceptible to certain illnesses. Tracking illnesses
from one
  generation of a family to the next can help identify illnesses for which the
  family is at risk. This may
allow family members, working with
their  physicians, to take steps to reduce their risk.

The tool guides
users  through a series of screens to record information for each family member
about  six
common diseases. Other conditions may also be added.
After the  information has been collected, a diagram
can be printed
and shared  with a physician.

All personal information is maintained on
the user's  computer. No information is given to the government.
Eventually, the  tool will be available in both English and Spanish.
Also, a print version will  be provided to
those who call the
Federal Citizen Information Center at  (888) 878-3256.

The federal
employees who have worked on this project,  from the National Institutes of
Health, Surgeon
General's office and  CDC, hope families will take
advantage of being together over the holidays to  compile
a health
history. "It is our hope as families gather this  holiday season, they'll take
the time to learn-and
record-their  families' health histories so
that they can continue to have years of family  gatherings together,"
said
Muin Khoury, MD, director of CDC's Office of  Genomics and Disease
Prevention.



MEDICAID  ALERT:

Medicare/Medicaid Information
regarding insurance with  medicare:

You automatically qualify for extra
help and don't need to  apply if you:

have Medicare and full coverage
from a state Medicaid  program that currently pays for your prescriptions.
You should join a  plan that meets your needs by December 31, 2005
because Medicaid will no longer  pay
for prescription drugs. If you
don't, Medicare will enroll you in a  plan effective January 1, 2006 so you
don't
miss a day of coverage. You  can drop the plan or switch to
another any time.


get help from your  state Medicaid program paying
your Medicare premiums (belong to a Medicare  Savings
Program). You
should join a plan that meets your needs by  December 31, 2005. If you haven't
signed up
by May 15, 2006, Medicare  will enroll you in a plan
effective June 1, 2006 so you don't have to pay a
penalty. You can
drop the plan or switch to another any  time.


get Supplemental
Security Income. You should join a plan that  meets your needs by December 31,
2005. If
you haven't signed up by May  15, 2006, Medicare will
enroll you in a plan effective June 1, 2006 so you
don't have to pay
a penalty. If Medicare enrolled you in a prescription  drug plan, you can switch
to another
plan one time before December 31,
  2006.


Appeals Form
If you are having trouble with medicare
denying  your compression garments, contact Bob Weiss.  He can
help
you with  your appeal and the form is above.  Email Bob at:
  lymphactivist@aol.com

Save Medicare
Act 2008
What To
  Do When Medicare Says 'No'
http://www.elderlawanswers.com/resources/article.asp?id=2334&Section=4&state=

Your doctor
  suggested you have a minor operation or procedure, you went ahead and had it
  done, and now
Medicare won't pay for it. What should you do?
  Appeal.
Your provider tells you that your lymphedema compression garments
are  not covered. What should you
do? Appeal. [Added by Bob
  Weiss]

Medicare covers procedures that are deemed medically necessary.
  "Appealing is easy and most people win
so it is worth your while to
  challenge a Medicare denial," says the Medicare Rights Center, a national
nonprofit organization. The denial of coverage may be due, for example,
to  a simple coding error in your
doctor's office.

People
have a  strong chance of winning their Medicare appeal. According to Center, 80
percent  of
Medicare Part A appeals and 92 percent of Part B appeals
turn out in  favor of the person appealing.

The Medicare Rights Center
offers the  following tips to maximize your success when appealing your
denial:

a..  Write "Please Review" on the bottom of your Medicare Summary
Notice (MSN), sign  the back and
send the original to the address
listed on your MSN by  certified mail or with delivery confirmation.
b..
Include a letter explaining  why the claim should be covered.
c.. When
possible, get a letter of support  from your doctor or other health care
provider explaining why the
service was "medically
necessary."
d.. Save photocopies and records of  all communications, whether
written or oral, with Medicare concerning
your denial.
e.. Keep
in mind that you only have up to 120 days from the  date on the MSN to submit an
appeal.
The Center notes that the appeals  process is slightly different if
you are in a private Medicare plan, like an
HMO or a PPO. One
difference is that you have only 60 days from the date on  the denial notice to
file an
appeal.

Resources:

For  information on how to
fight a hospital discharge, click here.

For more on  the Medicare Rights
Center, visit its Web site at  http://www.medicarerights.org

To download
Medicare appeal forms from the  government's Medicare website, click
  here.



--------------------------------------------------------------------------------------------

FILING
  A CLAIM FOR REIMBURSEMENT FOR COMPRESSION GARMENTS


* Garment
supplier  fills out an ABN and gives Beneficiary a copy. Beneficiary pays
garment fitter  and gets a
receipt. Make sure that this is the
latest version of Form  CMS-R-131. I have the version dated (03/08).
This is important since  the Section (G) Options were in reverse order
from earlier versions. The option  to be
chosen is the only one
which states in bold "I can appeal to  Medicare".

* If the Supplier
should choose to file the claim for the  beneficiary, they will file on a Form
1500. Ask that
they fill out Item  27 Acceptance of Assignment with
a "NO", and further place the note "Beneficiary  refuses
to assign
benefits" in Item 19. (see note below why Supplier  may not be motivated to file
for the beneficiary).

* Beneficiary submits  CMS form 1490 Patient's
Request for Medical Payment to Medicare requesting
reimbursement for
the garment listed on the ABN, and attaches receipt.  Block 6 Authorization says
"... and
request payment of medical  insurance benefits to me." just
above beneficiary's signature.

* Medicare  sends a denial directly to the
Beneficiary. Denial appears on the quarterly  Medicare Summary
Notice (MSN). After the headers on this form, the  sentence "This is a
summary of claims processed from ...
to ...".  Following this there
should be a section labeled "Part B Medical  Insurance-Unassigned Claims". In

the last column "See Notes Section"  there will be a series of code
letters denoting the reason for the denial.
There will also be
detailed instructions for appealing the decision. There  is a 120-day appeal
period after
which no appeal will be  allowed.

* Beneficiary
consults Bob Weiss [LymphActivist@aol.com] to  proceed further, i.e., several
more denials
will come down the pike  before it goes to an
administrative law judge... At this point I will need a  copy of
the
MSN and I will either guide the beneficiary in the first  appeal, or I will file
it on behalf of the beneficiary.
This first  appeal to an
"independent" Medicare Contractor is called a "Redetermination",  the next
appeal to a
"Medicare Quality Independent Contractor" or a  "DME
MAC" is a "Reconsideration", and the next appeal
is to an
  Administrative Law Judge (ALJ). None of these appeals costs any more than the
  cost of making
copies and postage. There is a 60-80% chance of a
  favorable determination by the ALJ. In the event that
the ALJ
renders  an unfavorable decision then we will appeal to the Medicare Appeals
Council,  where I run
about a 50% favorable rate.


IF the
Beneficiary  gets reimbursed after 2 years or so, the ABN states that "If
Medicare does pay,  you will
refund any payments I made to you, less
co-pays or  deductibles."  This puzzles me.   Does this mean that
Medicare will  reimburse the garment fitter directly?   (That's crazy
because it is definintely  not in a garment
fitter's interest to go
to the trouble of submitting  an ABN for a Beneficiary only to have to refund
their money
at a later  time). You are correct that the Supplier has
little incentive to file your  complaint. The supplier
receives a
reduced amount of reimbursement from  the retail price of the item, and if they
are a Medicare
Supplier they  are required to file a claim for
something they know will be denied. So they  will ask for
payment in
advance. So as long as they are filing on  behalf of the beneficiary it is
important for the
beneficiary to refuse  to assign benefits on the
Form 1500. That way there will be no refunds  necessary.

(Thanks to
therapist Kevern Hartmann for providing the  framework for this piece and
forcing me to
research the appeal process.  I would ask any reader
who discovers any errors or changes to the process to
contact me
immediately. Please remember that I am not allowed to provide  medical or legal
advice. All I
can do is to read the appropriate  regulations and
policies and tell you what my understanding is.)

Robert  Weiss,
M.S.
Lymphedema Patient
  Advocate
LymphActivist@aol.com
--------------------------------------------------------------------------------------------

Abstracted
  this from an article in the San Francisco Chronicle. This applies to denials of
  compression
bandages, garments and devices, which are medically
  required in the treatment of lymphedema.

Bob Weiss

Medical care's
  state of denial
Victoria Colliver, Chronicle Staff Writer

Monday,
June  23,
  2008

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/06/22/MNUK11C28G.DTL&tsp=1


What
  to do if you are denied medical care

If your health insurance carrier is
  refusing to approve treatment recommended by your doctor, you have a
number
of options. First, contact your health plan. You probably will have  to go
through the plan's internal
grievance process first. If time is  of
the essence, ask for an expedited review through the state.

Tips to  help
you get the care you need:


-- Review your health plan policy.  Many
are available online.

-- Make sure your doctor is aware of your  problem.
Sometimes the initial denial comes from the medical
group,  which is
charged with managing costs. In any case, your doctor's support is
  important.

-- Request the reason for the denial in writing. Take
detailed  notes of all conversations, including the date
and time of
the call and  the name of the person you speak with. Save copies of all
paperwork, and keep
these records in chronological order.

--
Act soon. If you wait  longer than six months, you could lose the right to file
a complaint, ask for an
independent medical review (also called an
IMR), or take other action  against your health plan such as
arbitration or a lawsuit. An IMR  decision is binding on the health
plan, but not the
  patient.
-------------------------------------------------------------------------------------------

NHIC
  Provider Education, Medicare Part B

Expiration of Therapy Cap
  Exceptions

The exceptions to outpatient therapy caps expire on June 30,
  2008.  Outpatient therapy service providers 
should not submit
claims  with the KX modifier for services furnished on or after July 1, 2008.  
To the 
extent possible, CMS is working with Congress, health care
providers,  and the beneficiary community to 
avoid disruption in
the delivery of  health care services and payment of outpatient physical
therapy, 
occupational therapy and speech-language pathology claims
for services  furnished by physicians, non- 
physician
practitioners, and therapists  paid under the physician fee schedule, beginning
July 1.    

For  physical therapy and speech language pathology services
combined, the limit on  incurred expenses  is
$1810.  For
occupational therapy services, the  limit is $1810.  Deductible and coinsurance
amounts 
applied to therapy  services count toward the amount
accrued before a cap is reached.   Therapy cap 
accruals began on
January 1, 2008, and some patients may have reached  the annual limits by June
30, 
2008.     

Providers may access  the accrued amount or
remaining amount of therapy services from the Medicare 
beneficiary
eligibility inquiry and response transactions.  Specifically:
o For CWF
users, the system returns the “applied” amount. See  CR4115 at  http://www.cms.
hhs.
gov/transmit tals/downloads/ /R759CP.pdf 
o For users of the
HETS 270/271, the system returns the “remaining” amount.  See the page 18 of the
 
270/271 user guide at  http://www.cms.  hhs.gov/HETSHelp
/Downloads/ HETS%20270-  271%20User%
20Compan  ion%20Guide. pdf   

o The Medicare contractors' Interactive Voice Response  units (IVR) return
either the remaining or  applied
amounts based upon  contractor
programming.  For those few contractors that do not provide  this
information on their IVRs, providers can call the contractors' customer
  service representatives.    

For additional information, Providers and
  Suppliers should also read the Medicare Claims Processing 
Manual,
  chapter 5, section 10. 2 at    http://www.cms. hhs.gov/manuals/ downloads/
  clm104c05TXT. pdf

Patients Who Have Reached Their Limit(s) on Outpatient
  Therapy Services: 
Note that patients who have reached their limit(s) on
  outpatient therapy services, other than those who 
reside in a
  Medicare-certified part of a skilled nursing facility, may obtain medically
  necessary therapy 
services that exceed the caps if the services
are  furnished and billed by the outpatient department of a 
hospital.  In  other settings, outpatient therapy services in excess of
the caps are not  covered, and the 
therapy provider may charge for
those services.  An  Advance Beneficiary Notice is recommended, but not 
required for  services that exceed therapy caps. 

An ABN is
available at the following  link:   http://www.cms. hhs.gov/BNI/ 02_ABNGABNL.

asp#TopOfPage  (click on ABN-CMS-R-131 Form).   In the box titled
"Reason Medicare will not  pay"
the following language is suggested
Medicare will not pay  more  than $1810 for expenses incurred for
physical therapy and  speech-language pathology services  combined or
for occupational services in  2008.

Patients may be referred to this
website for further information: 
http://www.medicare .gov/Publication
s/Pubs/pdf/ 10988.pdf which will be  activated by July 3, 2008.

We will
continue to be in communication with  you with further information about payment
of Medicare 
physician fee  schedule claims.  In addition, be on the
alert for more information about other  legislative 
provisions
which may affect you.

Reference:  JSM/TDL-08387; 
7/3/2008

----------------------------------------------------------------------------------

Extension
  of Therapy Cap Exceptions


July 16, 2008  

The Medicare
  Improvements for Patients and Providers Act of 2008 was enacted on July 15,
  2008.  One
provision of this legislation extends the effective date
of  the exceptions process to the therapy caps to
December 31, 2009.
  Outpatient therapy service providers may now resume submitting claims with the
  KX
modifier for therapy services that exceed the cap furnished on
or  after July 1, 2008. 

For physical therapy and speech language
pathology  services combined, the limit on incurred expenses is
$1810 for calendar  year 2008.  For occupational therapy services, the
limit is $1810.  Deductible  and
coinsurance amounts applied to
therapy services count toward the  amount accrued before a cap is
reached.   Services that meet the  exceptions criteria and report the KX
modifier will be paid beyond this
limit. 

Before this
legislation was enacted, outpatient therapy  service providers were previously
instructed to not
submit the KX  modifier on claims for services
furnished on or after July 1, 2008.  The  extension of the
therapy
cap exceptions is retroactive to July 1, 2008.   As a result, providers may have
already submitted
some claims without  the KX modifier that would
qualify for an exception. 

Providers  submitting these claims using the
837 institutional electronic claim format or  the UB-04 paper
claim
format would have had these claims rejected for  exceeding the cap.   These
providers should resubmit
these claims  appending the KX modifier so
they may now be processed and paid.  Providers  submitting
these
claims using the 837 professional electronic claim  format or the CMS-1500 paper
claim format would
have had these claims  denied for exceeding the
cap.   These providers should request to have their  claims
adjusted
in order to have the contractor pay the claim.   

In all cases, if the
beneficiary was notified of their liability and  the beneficiary made payment
for services that
now qualify for  exceptions, any such payments
should be refunded to the
  beneficiary.
---------------------------------------------------------------------------------------

Seven
  Mistakes to Avoid When Seeking Social Security Disability BenefitsAllsup
  outlines missteps that can
be obstacles when applying for SSDI
  benefits.Belleville, Ill. (Vocus) July 11, 2008 -- People with severe
disabilities
know what it means to wait. They wait medical test results;  they wait doctors’
diagnoses and they
wait for answers to their  questions about the
future. Delays are typical for people filing for Social  Security
Disability Insurance
  (http://allsup.com/About-SSDI/Free-SSDI-Evaluation.aspx) (SSDI) benefits, but
  there
are ways to avoid common mistakes that make the process even
more  difficult to navigate, according to
Allsup
  (http://allsup.com/Home.aspx). Founded in 1984 and headquartered near St.
Louis,  Allsup
represents people nationwide for their entitled SSDI
  benefits.Two-thirds of all SSDI applicants will have
their initial
  claim denied. If they appeal, and even if they are successful, they will go
  through several
additional steps and may wait two years or longer
  before they ev er see a disability payment. There are
some
missteps,  however, that can actually add time and increase the delay for an
SSDI award,  according to
Allsup.“Social Security disability
payments are a  significant, and often the sole, income source for millions of

individuals with disabilities and their families,” said Edward
Swierczek  (http://www.allsup.com/About-
Us/News-Room/Resources-for-Journalists/Allsup-Experts/Edward-Swierczek.aspx),
  senior claimant
representative with Allsup. “Unfortunately, people
with  disabilities often make mistakes in applying for their
SSDI
benefits.  This may result in even more delays, which puts more stress on what
could  already be a
precarious financial situation.”To help educate
claimants,  Allsup provides the following information on seven
common mistakes  people make when filing for SSDI benefits.Seven Common
Mistakes When Filing for
SSDI1. Going into the process uneducated.
Some people believe it’s just  a matter of filling out a few forms,
sending them in and waiting for  their checks. They would be surprised
to find out just how complicated the
SSDI process really is. The
Social Security Administration follows a  five-step sequential evaluation
process
to determine if an individual  qualifies for disability
benefits (http://allsup.com/About-SSDI/Why-You-Want-
SSDI.aspx),
explained Swierczek, including:*    You must not be gainfully  employed, which
is defined as
earning $940 a month or more, *    Your  condition is
severe, meaning it interferes with basic activities of
work, *   
Your condition is on the Social Security Administration’s list  of disabling
conditions, or medically
equals one of the disabling  conditions on
the list, and you will be disabled for more than 12 months, *    You
are not able to do the work you had been doing before the  impairment,
and, *    You can’t perform any
other type of work. “You  have to
meet the first two criteria before the Social Security Administration  will
consider your claim,” said Swierczek, who has more than 30 years  of
experience helping individuals through
the complexities of the SSDI
  application process (http://allsup.com/About-SSDI/SSDI-Process.aspx). “If
you’re a 40-year-old ironworker who hurt your back, the Social Security
  Administration may find that you
are not disabled if you can do
desk  work. You may not think you can, but if you don’t provide compelling
evidence20why you can’t, they will deny your claim,” he said.2. Going
  through the SSDI process alone.
Individuals who apply for Social
  Security Disability Insurance benefits (http://www.allsup.com/About-
SSDI/Choosing-Representation.aspx) without representation are more
likely  to have their claim denied.
“Working with government
agencies and  understanding the nuances of what’s needed to comply with the
regulation isn’t something the average person is aware of,” said Allsup
  senior claimant representative David
Bueltemann
  (http://www.allsup.com/About-Us/News-Room/Resources-for-Journalists/Allsup-
Experts/David-Bueltemann.aspx), who has successfully represented
thousands  of SSDI applicants.“Just as
people hire accountants to
complete their  tax returns and represent them before the Internal Revenue
Service if  they’re audited, individuals are recognizing they need
representation when they  go into the Social
Security Disability
Insurance process,” he added.3.  Underestimating the impact of your disability.

Sometimes pride leads  people to underplay the extent of their
disabilities because they have endured a
condition so long that they
have learned how to cope with the stress of  daily life. But many people
underestima te how much their disability  affects their day-to-day
lives. A good example, Bueltemann
explained,  is a 50-year-old
grandmother who tells the state Disability Determination  Service (DDS) that she

takes care of her grandchildren. If the woman  doesn’t explain that
the children are teen-agers and self-
sufficient,  the DDS may deny
her claim because it believes that she is capable of working in  a day care
center.4. Exaggerating the impact of your disability. On the  other end
of the spectrum are people who want
to make their condition  appear
worse than it is. For example, a man who uses a cane at a hearing before  an
administrative law judge but doesn’t normally use a cane would be
  over-representing his condition. “If the
judge asks to look at the
cane  and sees the tip is not worn, the claim is immediately suspect, even
though the
claimant may have had a legitimate case if he’d just
stuck to the  unexaggerated truth,” Swierczek explained.
“It is
important to  elaborate, but not exaggerate.”5. Being vague about your work
history. Knowing  what
the expectations are for your work, and
showing accurately from  the outset why you can’t perform this
work
any longer, is an essential  part of qualifying for SSDI benefits
(http://www.allsup.com/About-
SSDI/SSDI-Guidelines-by-Disability.aspx). For example , Swierczek said,
a  service technician might be
required to drive for extended
periods as  part of the job. “If your impairment means you can only drive for

10  minutes without experiencing extreme pain, yet your job requires
you drive in  60-minute stretches, you
need to make it clear on your
disability  application what the work expectations are and what your limitations

are,” said Swierczek. “Otherwise, you may end up in double jeopardy:
Your  disability claim is rejected
because the Social Security
Administration  believes you can still perform your work,” he said. “But you’re

out of  work because you really can’t meet the requirements of the
job.”6. Missing the  appeals deadline. The
Social Security
Administration denies more than  60 percent of all initial SSDI applications,
but there is a
formal  appeals process with three levels. If you are
rejected at any level, you have  only 60 days to appeal to
the next
level. If you miss the deadline, you  need to start the process from the
beginning. If you’ve applied
on your  own and received a denial,
it’s not too late to choose an SSDI representative  (http://www.allsup.
com/Allsup-Representation/How-It-Works-At-Allsup.aspx),
such as Allsup, to  handle the appeal and
continue with your case.
Taking this step may  make the differenc e in experiencing further delays to
receiving
your  SSDI benefits.7. Giving up. The process can be
excruciatingly long and  cumbersome. Nearly 750,000
people are
waiting for a hearing before an  administrative law judge, which is only one
level of the SSDI
appeals  process. For individuals already facing
significant physical or mental  disabilities, this delay can add
to
the difficulty. Bueltemann,  however, is quick to point out that receiving SSDI
is a benefit that individuals
with disabilities and their families
have earned, if they meet the SSDI  requirements. An SSDI award also is
essential in securing other forms  of financial support, including
Medicare benefits (http://www.allsup.
com/Financial-Matters/Managing-Healthcare-Costs/Medicare.aspx) and
  retirement protection. “It may not
be as easy as it should be to
  receive your payments, but don’t give up,” Bueltemann said. “Make sure you
have good representation and don’t lose hope that you can secure your
  benefits.”ABOUT ALLSUPAllsup,
Belleville, Ill., is a leading
nationwide  provider of financial and healthcare related services to people with

disabilities. Founded in 1984, Allsup has helped more than 100,000
people  receive their entitled Social
Security Disability Insurance
and  Medicare benefits. Allsup employs more than 500 professionals who
deliver
se rvices directly to consumers and their families, or through  their employers
and long-term disability
insurance carriers. For more  information,
visit www.Allsup.com.Contacts: Allsup - Rebecca Ray(800) 854-
1418,
ext. 5065 Dan Allsup, ext.
  5760.
----------------------------------------------------------------------------------------


I
  have no idea if this is good or not, cause if the cap is 1810, my
therapy
for  less than 2 weeks 3 years ago was almost $9,000 so what
good is 1810?
Well I  hope this does help someone out there and that
it is a good
  thing.


If you are on Medicare and are provided lymphedema treatment
  by a Medicare-approved physical
therapist, you do not pay (except
for  deductables and 20% co-pay) for the service up to $1800. The
therapist  is not alowed to charge any more, and (s)he is reimbursed by
Medicare. The  reimbursement rates
vary from state to state, but run
about $25 per  unit, with 3-4 units per visit, that provides about 15-20
visits.

But  this annual limit has been suspended for many years by
Congress, but is now back  in place. But
Congress has also said that
in cases where there is a  medical necessity for more than the capped amount per

year, there would  be an exception process for certain conditions.
Last year lymphedema was on the  list of
exception conditions, so
the limit did not apply. But starting  July 1, the exception process
expired.

This new law just put the  exception process back. That's good,
since if you need more than 15-20
treatments in any one year for
your lymphedema, you can have them  justified.

I have no idea how your
therapist charged you $9,000 for a  course of lymphedema treatment. Did that
cost
include bandages or  garments (not covered by
Medicare)?

Bob Weiss
Lymphedema Patient
  Advocate

-----------------------------------------------------------------------------------

Bob...
  I just got a new prescription for Compression hose... I have never worn any...
I  just can't afford them
right now.. I had one RX but did not even
try to  get them because I knew that I could not afford them.. I am
on  Medicaid.. should I try with this RX and then when I get turned down
then try  the appeals process or
should I wait until I can afford a
pair and then  try and after I have to pay for them go for an appeal? I really

just  can't afford them.. I can't afford my treatment at all.. so I
am just waiting in  limbo right now... It is a little
hard to do
when I get fluid in my  knees and can't stand up on my own at times... any
advice???? Thanks,
Marbeth :)


Marbeth,

Find a
Medicare approved supplier and  give them a copy (you keep the original) of the
doctor's prescrition
and ask them to request an advanced approval to
Medicaid and to Medicare if  you are on both. It will be
denied, but
you will then have something to  appeal and a claim number that can be tracked.
The prescription
should  clearly state that the stocking is
necessary to treat your lymphedema, with the  appropriate diagnostic
code.

Bob
  Weiss

----------------------------------------------------------------------------------

By
  accepting the denial of treatment or a compression garment on the basis of the
  the letter of denial which
says it is not covered, we allow this
  insurance travesty to continue. Appeal each and every denial of
lymphedema treatment. If you run into what appears to be a brick wall
  contact me and I'll see how to
approach an appeal.

Bob
  Weiss
Lymphedema Treament
  Advocate
=================================================================

San
  Francisco Chronicle Examines Health Insurance Claim Denials

The San
  Francisco Chronicle on Monday examined how "[e]ach year, thousands of
  Californians find
themselves at odds with their health insurers
over  whether they, as patients, should get the treatment their
doctors  prescribed."

Insurers say that physicians do not always
prescribe the  most cost-effective treatments. Anthem Blue Cross
says it follows  strict protocols in denying care and relies on medical
evidence to determine  what care is
appropriate. Michael Belman,
Anthem's medical director,  said, "Even in a dire situation, it is ethically
appropriate to  withhold treatment if it's not effective." Alan Sokolow,
chief medical officer  for Blue Shield of
California, said, "We
think that is our job -- to  help patients and providers apply the benefit
package the
patient has,  the dollars they put for insurance
coverage and health care, in the most  appropriate and effective
way," adding that patients should appeal  denials if they
disagree.

According to the Chronicle, in 2007, the  state's HMO Help
Center received about 90,000 calls from
individuals  with health
insurance disputes. The majority of disputes involved whether  treatment or
procedures prescribed by physicians were "medically  necessary" or
considered "experimental" or
"investigational." The state
  Department of Insurance, which regulates a smaller number of insurance plans,

received 35,280 complaints and resolved 262 independent medical
review  cases in 2007. The Department
of Managed Health Care since
2001 has  offered third-party medical reviews and has resolved 1,716 IMRs
since  2007. According to DMHC, roughly 40% of decisions are settled in
favor of the  patient.

Jerry Flanagan, health advocate for Consumer
Watchdog, said that  issues arise because health insurers "are
going
back to the old  strategies of the '90s, when they interrupted care on the front
end by denying  or
delaying treatment offered by a doctor." He said
insurers hope  patients will not dispute the decisions or
settle for
less, in order to  save money -- a statement that insurers dispute.

The
Chronicle also  profiled the cases of three individuals whose claims were denied
by insurers  (Colliver,
San Francisco Chronicle,
  6/23).


------------------------------------------------------------------------------
Analysis
Examines  Cost Of Employer-Sponsored Health Coverage; Report Looks At Medicare
Part D
Plan
Changes;  More
http://www.medicalnewstoday.com/articles/130355.php

Connecticut
  Attorney General Calls For Rebidding Of State Health Insurance Programs,
  Governor Says
Move Is Unnecessary
http://www.medicalnewstoday.com/articles/130352.php

Michigan
Attorney  General Says Lawmakers Should Not Pass Health Insurance Legislation In
Lame-Duck
Session
http://www.medicalnewstoday.com/articles/130351.php

Average Annual
  Deductible For Individual Employer-Sponsored PPO Now Over $1,000, According To

Survey
http://www.medicalnewstoday.com/articles/130349.php

AHIP, BCBS Say
  They Support Guaranteed Coverage For People With Pre-Existing Health
Conditions,
As Long As All Individuals Required To Obtain
Cover
http://www.medicalnewstoday.com/articles/130344.php

Senate Leaders
  Hold Closed-Door Meeting To Discuss Health Care Overhaul
  Legislation
http://www.medicalnewstoday.com/articles/130342.php

Obama Appoints
  Former Sen. Daschle As HHS Secretary, Democratic Officials
  Say
http://www.medicalnewstoday.com/articles/130341.php

Board Adopts
  Recommendations To Overhaul Oregon Health Care System
http://www.medicalnewstoday.com/articles/130146.php

AARP Hires
  Outside Investigator To Examine Sales Of Limited-Coverage
  Plans
http://www.medicalnewstoday.com/articles/130138.php

President-Elect  Obama Likely To
Pick CBO Director Orszag As Director Of U.S. Office Of  Management
And Budget
http://www.medicalnewstoday.com/articles/130135.php

Automaker
  Bankruptcies Would Require Taxpayers To Pay $3B Annually For Health Care, UAW

President Gettelfinger Says
http://www.medicalnewstoday.com/articles/130133.php

Sen. Kennedy
Taps  Senators To Lead Various Working Groups Aimed At Improving U.S. Health
  Care
http://www.medicalnewstoday.com/articles/130132.php

Several Recent
  Editorials, Opinion Pieces Address Health Care Reform
http://www.medicalnewstoday.com/articles/129958.php

New York Times
  Editorial Calls U.S. Chronic Disease Care 'Abysmal'
http://www.medicalnewstoday.com/articles/129956.php

Kaiser Daily
  Health Policy Report Feature Highlights Recent Blog Entries
http://www.medicalnewstoday.com/articles/129955.php

Connecticut
Gov.  Rell Keeps HUSKY Kids Insurance Program Separate From Adult Coverage
  Program
http://www.medicalnewstoday.com/articles/129954.php

Growing Number
Of  Companies Provide On-Site Health Care Services For
Workers
http://www.medicalnewstoday.com/articles/129949.php

Coalition Of
  National Organizations Urges Steps To Reduce Health Care Costs, Improve
  Quality
http://www.medicalnewstoday.com/articles/129948.php

Sen. Edward
  Kennedy Plans To Introduce Universal Health Care Bill
http://www.medicalnewstoday.com/articles/129943.php

Health
Insurance  Premiums Rise Up To 33 Percent With State Pricing Rule,
USA
http://www.medicalnewstoday.com/articles/129802.php

Boston Globe
  Examines Discrepancies In Massachusetts Hospitals' Insurance Reimbursement
  Payments
http://www.medicalnewstoday.com/articles/129763.php

New York
Attorney  General Investigates Relationships Between Colleges, Health Insurers
That Cover
Students
http://www.medicalnewstoday.com/articles/129760.php

Wall Street
  Journal Examines Steep Health Plan Premium Increases For Many Sm Businesses In
  2009;
New York Times Examines High-Deductible Health
  Plans
http://www.medicalnewstoday.com/articles/129759.php

President-Elect  Barack Obama,
Congressional Democrats Frame Health Care, Other Proposals As  Job-
Creation Plans
http://www.medicalnewstoday.com/articles/129756.php

Study Shows
Half  Of Individual Health Insurance Policy Holders Paid Under $130 Per Month,
  USA
http://www.medicalnewstoday.com/articles/129651.php

Briefs
Highlight  Issues Involving Integration Of Mental Health Services In Health
Reform;  Statehealthfacts.
org Adds New, Updated Data;
More
http://www.medicalnewstoday.com/articles/129570.php

Arizona
Rejects  Ballot Measure To Make Mandated Health Coverage
Illegal
http://www.medicalnewstoday.com/articles/129566.php

Philadelphia
  Inquirer Series Examines Health Care Delays For Patients Without Health
  Insurance
http://www.medicalnewstoday.com/articles/129563.php

PhRMA To
Launch  Ad Campaign Lauding Free-Market Health Care System; SEIU Pushes For
Health
Reform
http://www.medicalnewstoday.com/articles/129560.php

-------------------------------------------------------------------------------------------------

EE
  page 11 --
topic 08.71

Garments to be discussed :
  FLEXITOUCH.

We need to continue to contact our local politicians to
  continue to push for
all lymphedema garments expenses to be
  covered!
Thanks Lisa for the heads-up.

This request is for Medicare
  Codes for the body garments used with the Flexitouch pneumatic compression
controller. They are coded as "durable medical equipment" since they are
  used in conjunction with a piece of
durable medical equipment. This
  ruling will in no way affect coverage of compression bandages or garments,
which are a different Medicare benefit category (i.e. "prosthetic
  devices").

I'm afraid that while contacting our local politicians serves
  a valuable educational function, it will not achieve
coverage
without  either a new law or by forcing CMS to re-interpret the current law. And
to do  the latter,
there must be a ground-swell of appeals from
lymphedema  patients who are denied coverage for their
garments.

I will make  this offer: If you file a claim for the
garments or bandaging kits that you paid  for in the last couple
of
months, when the denial comes from your  insurance company or from Medicare, I
will help you file the
three  appeals necessary to reach an
Administrative Law Judge. At this point you have a  good chance of
being reimbursed. I do not charge for this help. I'm  trying to get
favorable decisions from as many different
ALJs as I can.  Then I
will confront CMS for a change in their interpretation of the Social  Security
Act.

I will also help your Congressional representative draft  and
introduce a bill to change Medicare, if you can
interest him or her
  in your cause.

Robert Weiss, M.S.
Lymphedema Treatment
  Advocate
National Lymphedema
  Network

-------------------------------------------------------------------

There
  have been recent "clarifications" to the "incident to" physician services rules
  which may impact
provision of therapy services for some lymphedema
  therapists. The changes to the policies are summarized
  in

http://www.cms.  hhs.gov/MLNMatte
rsArticles/ downloads/ MM5288.pdf

with the
  full-text policy revisions given in

http://www.cms.  hhs.gov/Transmit
tals/downloads/ R87BP.pdf

-------------------------------------------------------------------------------------------

Settlement
  to Ease Drug Costs for Some on Medicare

By ROBERT
  PEAR
http://www.nytimes.com/2008/06/20/health/policy/20drug.html?_r=1&ref=health&oref=slogin
Published:
June  20, 2008
WASHINGTON - The Bush administration promised on Thursday to
provide  new
protections for low-income Medicare beneficiaries to ensure they
can  get
prescription drugs promptly, at minimal cost.

The promise
came in  the proposed settlement of a nationwide class-action lawsuit
filed
on behalf  of hundreds of thousands of people who have had difficulty
getting
the  medicines they need.

Under the 2003 Medicare law, more than six
million  people eligible for both
Medicare and Medicaid are entitled to extra
help  with their drug costs. But in
many cases, they could not get the
assistance,  so they did not receive the drugs
they needed, or they
experienced long  delays.

In early 2006, low-income beneficiaries were
often overcharged,  and some were
turned away from pharmacies without getting
their medications.  Several states
declared public health emergencies, and
many stepped in to pay  for prescriptions
that should have been covered by
the federal Medicare  program.

Under the proposed settlement, filed
Thursday with the United  States District
Court in San Francisco, federal
Medicare officials promised  to speed up the
process of providing extra help
to low-income people, who now  could qualify
within days, rather than weeks
or months.

Drug benefits  are delivered by private insurers under
contract to Medicare.
Under the  settlement, these insurers will have to
provide medications at minimal
cost  for any Medicare recipients who prove
they have low incomes and qualify  for
extra help.

For most people
with incomes less than the poverty  level ($10,400 a year for an
individual),
the maximum co-payment is $1.05 for  a generic or preferred
brand-name drug
and $3.10 for other prescription  drugs.

But many beneficiaries have been
asked to pay much higher amounts,  from $30 to
$75 or more, because the
evidence of their low-income status was  not properly
shared among federal
and state agencies, insurance companies and  pharmacies.

"This settlement
agreement is a victory for many of the  nation's most vulnerable
citizens,
who have faced life-threatening delays in  obtaining vital
medications," said
Kevin Prindiville, a lawyer at the  National Senior Citizens
Law Center,
which filed the lawsuit with another  nonprofit group, the Center
for
Medicare Advocacy.

Gill Deford, a  lawyer at the Center for
Medicare Advocacy, said the settlement
would "help  hundreds of thousands of
people a year get their prescription drugs
more  quickly, at nominal
cost."

Jeff Nelligan, a spokesman for the federal  Centers for Medicare
and Medicaid
Services, said federal officials had  "worked tirelessly" to
ensure that Medicare
recipients could fill their  prescriptions. He refused
to comment on the
substance of the settlement,  noting that it was subject to
approval by Judge
Thelton E. Henderson of  Federal District Court in
California.

States administer the Medicaid  program. They have crucial
information showing
whether Medicare beneficiaries  are also enrolled in
Medicaid and therefore
eligible for extra help with  their drug
costs.

Under the settlement, if a beneficiary claims to be  eligible for
the low-income
subsidy but does not have the documents to prove  it, and if
the person is about
to run out of a medication, federal officials  would
immediately contact the
state Medicaid agency to check whether the  person
had been on
  Medicaid.

--------------------------------------------------------------------------------

News
  from New York State
Assemblyman ALAN N. MAISEL
59th ASSEMBLY
  DISTRICT

Date: June 23, 2008  


Assembly Passes Maisel
Measure  To
Raise Awareness of Lymphedema



Today, in Albany,
Assemblyman  Alan Maisel (D-Kings County) announced passage in the Assembly of

legislation to promote lymphedema and lymphatic disease reporting
and  awareness (A05892B). TThe
measure requires health care
providers, who  are already required to report cases of cancer or oother
malignant  disease, to also report instances of lymphedema related to
cancer treatment in  their patients. This
legislation also requires
the Department of Health  to develop a health care and wellness education and

outreach program  for those seeking information on either primary or
secondary  lymphedema.

"Lymphedema is not a high profile disease like
cancer or  diabetes that generates a lot of press or mmoney
for
research, yet it  affects an estimated six million men, women and children in
the United States,"  stated
Maisel. "The lymphatic system is vital
to the health of every  individual as it is an integral part of tthe immune
system.” Lymphedema  is an accumulation of lymphatic fluid that causes
painful, disfiguring  sswelling, usually
in the arms or legs. There
are two major types of  lymphedema: primary (congenital) and ssecondary (caused

by tissue  injury, scarring, lymph node removal, or
infection).

"The largest group  of people who acquire secondary
lymphedema arc cancer patients, including  those  with
breast,
prostate, lung, and melanoma patients," stated Maisel.  "This bill helps to
ensure that when
lymphedema is acquired from the  life-saving cancer
treatments, these instances of disease are also rreported
to the
cancer registry. This will help raise awareness of the disease and  hopefully
increase the mmoney
raised to fund additional research to  help find
the cause of and cure for lymphatic diseases, lymphedema,
and
  related disorders."

"It amazes me that despite the essential role the
  lymphatic system plays in human health, awareness,
education and
  research have been relatively neglected," stated Maisel. "This lack of focus
has  created
barriers to effective delivery of health care and
public  education about these diseases, its diagnosis,
treatment,
therapy and  long-term care. This legislation, which is on third reading in the
Senate, is  just the first
step in raising public awareness about
lymphedema." 


=======================================================================

To
  lymphedema patients, therapists and activists:

A wonderful article on
  lymphedema was printed in the prestigious cancer journal "CA A Cancer Journal
  for
Clinicians" [CA Cancer J Clin 2009;59;8-24] written by by Brian
D.  Lawenda, Tammy E. Mondry and
Peter A. S.
Johnstone.

"Lymphedema:  A primer on the identification and management of
a chronic condition in  oncologic treatment"
can be downloaded from
URL  <http://caonline.amcancersoc.org/cgi/reprint/59/1/8>

An
  accompanying description of lymphedema and its treatment can also be downloaded
  at the same source
from URL <http://caonline.amcancersoc.org/cgi/content/full/59/1/25>

I
  urge all of the readers of this message to download these references,  print
  them out, and bring copies to
your physicians, oncologists, and 
medical and insurance staffs. This is a well written and authoritative 
reference which should be brought to the attention of all medical
providers  and insurers.

Robert Weiss, M.S.
Lymphedema Treatment
  Advocate
National Lymphedema
  Network

=======================================================================

Written
  Clarification on Medicare for Patients and Providers Act of 2008
  (MIPPA)



MIPPA section 154(b) added a new subparagraph (F) to
  section 1834(a)(20) of the Social Security Act. 
This subparagraph
  states that eligible professionals and other persons are exempt from meeting
the
September 30, 2009 accreditation deadline that generally applies
to  other DMEPOS suppliers unless 
CMS  determines that the quality
  standards are specifically designed to apply to such professionals and
persons.  



The eligible professionals to whom this
  exemption applies are set out at sections 1848(k)(3)(B) and 1861(r)
of  the Act, and include Physicians, Physical Therapists, Occupational
Therapists,  Qualified Speech-
Language Pathologists, Physician
Assistants, and Nurse  Practitioners.



Additionally, section
154(b) of MIPPA allows the  Secretary to specify “other persons” that, like the
eligible
professionals described above, are exempt from meeting the
accreditation  requirements unless  CMS 
determines that the quality
standards are  specifically designed to apply to such other persons.  At this
time,
we  are defining “such other persons” as Orthotists,
Prosthetists, Opticians, and  Audiologists.



CMS will define how
the quality standards apply to  these eligible professionals and other persons
by
rulemaking in  2009.



Individuals not included in
this exemption list, such as  pedorthotists, mastectomy fitters, orthopaedic
fitters/
technicians or  athletic trainers applying for Medicare
enrollment in order to bill for Medicare  part B services
are not
exempt from meeting the September 30, 2009  deadline for DMEPOS
  accreditation.


-----------------------------------------------------------------

New
  HCPCS Codes

The following new codes are effective for dates of service
on  or after January 1, 2009. If billed before
January 1, 2009, the
code  will be returned as unprocessable or denied as an invalid code. The
appearance
of a HCPCS code in the list below does not necessarily
indicate  coverage.

HCPCS Code
Description

A6545
GRADIENT
COMPRESSION  WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG,
EACH

E0656
SEGMENTAL  PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC
COMPRESSOR,
TRUNK

E0657
SEGMENTAL PNEUMATIC APPLIANCE FOR
USE WITH PNEUMATIC  COMPRESSOR, CHEST

Verbiage Changes for
2008

The following list  contains HCPCS codes for which verbiage will be
changed effective January 1,  2009.

L4360
WALKING BOOT, PNEUMATIC
AND/OR VACUUM, WITH OR WITHOUT  JOINTS, WITH OR
WITHOUT INTERFACE
MATERIAL, PREFABRICATED, INCLUDES  FITTING AND
ADJUSTMENT

=======================================================================

December
  05, 2008

The Advance Beneficiary Notice of Noncoverage (ABN) and Correct
  Use of Modifiers GA and GY -
Revised

Both Medicare
beneficiaries  and durable medical equipment, prosthetics, orthotics, and
supplies
(DMEPOS) suppliers have certain rights and protections
related to financial  liability under the Fee-for-
Service (FFS)
Medicare program. These  financial liability and appeal rights and protections
are
communicated  to beneficiaries through Advance Beneficiary
Notices of Noncoverage (ABN) given  by
suppliers.
An ABN is a
written notice the supplier gives to a  Medicare beneficiary before providing
items and or
services that are  expected to be denied by Medicare
based on one of the following statutory  exclusions:

1.     The item or
service may be denied as "not reasonable  and necessary" pursuant to Section
1862(a)(1)
of the Social Security  Act

2.     The item or
service may be denied due to an unsolicited  telephone contact pursuant to
Section 1834(a)
(17)(B)

3.     The  supplier number
requirements not being met pursuant to Section  1834(j)(1)

4.     Denial
of a request for Advance Determination of  Medicare Coverage (ADMC) pursuant to
Section
1834(a)(15)

When an  item or service is provided to a
Medicare beneficiary and is expected to be  denied based on one
of
the four exclusions listed above, it is the  responsibility of the supplier to
notify the beneficiary in writing
through the use of the ABN before
the item or service is delivered or  purchased. If the supplier issues a
properly executed ABN with Option 1  selected by the beneficiary, the
DMEPOS supplier must submit the
claim  to Medicare using the GA
modifier on each Healthcare Common Procedural Coding  System
(HCPCS)
code that is expected to be denied. The GA modifier  indicates that the supplier
has a waiver of
liability statement on  file.

Statutorily
Excluded Items

The GY modifier indicates that an  item or service is
statutorily excluded or does not meet the definition of
any Medicare
benefit. Some local coverage determinations (LCD) require the  use of the GY
modifier when
the item or service may be excluded from  coverage. In
this situation, suppliers are instructed to code the
claim  with the
appropriate HCPCS code indicated in the LCD and append the GY modifier.  Some

examples of statutory exclusions where the GY modifier is required
  per policy would include:

•     An infusion drug not administered using
a  durable infusion pump

•     A wheelchair that is for use for mobility
  outside the home

To determine if an exclusion of Medicare benefits
exist,  suppliers must review the applicable LCD and
policy article
for the  item or service being provided.

Suppliers are reminded that
modifiers GA  and GY should never be coded together on the same line for the
same  HCPCS code. It is important to distinguish situations in which an
item is denied  because it is statutorily
excluded or does not meet
the definition of  any Medicare benefit from those situations in which at item
is
denied  because it is not reasonable and necessary. Some examples
of statutorily  excluded items or situations
include, but are not
limited to:

•     eyeglasses or contact lenses-except those provided
following cataract  removal or other cause of
aphakia;

•    
Durable Medical  Equipment and related accessories and supplies provided to
patients in nursing
facilities;

•     personal comfort items;
and

•     orthopedic shoes or shoe inserts-other than those covered under
the  therapeutic shoes for diabetics
benefit or those that are
attached to a  covered leg brace.

Some examples of items or situations
which do not meet  the definition of a Medicare benefit include, but are
not limited  to:

•     Parenteral or enteral nutrients that are
used to treat a  temporary (rather than permanent) condition;

•    
Enteral nutrients that  are administered orally;

•     Infusion drugs
that are not administered  through a durable infusion pump;

•    
Surgical dressings that are used  to cleanse a wound, clean intact skin, or
provide protection to intact
skin;

•     Irrigation supplies
that are used to irrigate the skin  or wounds;

•     Immunosuppressive
drugs when they are used for  conditions other than following organ
transplants;

•     Most oral  drugs;

•     Oral anticancer drugs
when there is no injectable or  infusion form of the drug;

•    
Nondurable items (that are not covered  under any other benefit category);
• 
    e.g., compression stockings and  sleeves;

•     Durable items that are
not primarily designed to serve a  medical purpose;
•     e.g., exercise
equipment.


To access the  LCDs and policy articles, please visit the
DME MAC A Web site at: http://www.
medicarenhic.com/dme click on the
LCDs/Medical Policies link in the left  hand navigation under Medical
Review.

Voluntary
  Notification

Under the new instruction for the revised ABN, the Centers
  for Medicare & Medicaid Services (CMS)
advise that this form
may be  used to voluntarily notify Medicare beneficiaries of an expected
noncovered
denial of Medicare payment due to the statutory exclusion
of an item or  service, or the item or service not
meeting the
definition of any  Medicare benefit.

Section 1848(g)(4) of the Social
Security Act states  that items that are categorically excluded from
Medicare benefits (i.e.  hearing aids, personal comfort items, etc.) are
not required to be submitted to  the
Medicare program by the
supplier. However, if the beneficiary  requests the supplier to submit the claim
to
Medicare, the claim should  be coded with the designated HCPCS,
however, neither modifiers GA nor GY
are required. The supplier and
the Medicare beneficiary will receive a  patient responsibility denial for the

noncovered services.

For  additional instruction regarding
the proper execution of an ABN, suppliers are  encouraged to review the
CMS Internet-Only Manual Medicare Claims  Processing Manual, Chapter 30,
"Financial Liability
Protections,"  Sections 50 and 60 at:
  http://www.cms.hhs.gov/manuals

========================================================================
====================
The official Medicare Contractor or Supplier
  position is that compression garments are not covered. In fact
the
  policy explicitly states:

•     Nondurable items (that are not covered
  under any other benefit category);
•     e.g., compression stockings and
  sleeves;

But recent Administrative Law Judge decisions are that these
  compression garments DO meet the statutory
definition of
"prosthetic  devices" when they are used in the compression therapy for
lymphedema, and ARE
covered. But until the policies are rewritten
Beneficiaries are forced  to pay in advance, sign an ABN Form,
and
make an appeal of the denied  claim. Under these conditions note that the
Medicare Supplier MUST file
a claim.

I am available to help
Beneficiaries with their appeals of  denied claims.

Robert Weiss,
M.S.
Lymphedema Patient  Advocate
National Lymphedema
  Network

LymphActivist

------------------------------------------------------------

The
  bottom line is that compression bandage systems and compression garments remain
  NON-COVERED
in the treatment of lymphedema in the absense of an
open  venous stasis ulcer.

A new CircAid garment has been added to the
HCPCS  Coding but this below-the-knee device is covered
only in the
presence  of an open venous ulcer.

Revisions to the Surgical Dressing LCD
effective  January 1, 2009 in the following states:
Connecticut
District
of  Columbia
Delaware
Massachusetts
Maryland
Maine
New
  Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode
  Island
Vermont

Surgical Dressings  LCD for Surgical Dressings
  (L11471)
Revision Effective Date:   01/01/2009
INDICATIONS AND
LIMITATIONS  OF COVERAGE:
Added:   Frequency of replacement for compression
wrap  (A6545).
Coverage of a non-elastic gradient compression wrap (A6545) is
  limited to one per 6 months per
leg. Quantities exceeding this amount will
be  denied as not medically necessary. Refer to Policy
Article for statement
  concerning noncoverage if the ulcer has healed.

LIGHT COMPRESSION
BANDAGE  (A6448-A6450), MODERATE/HIGH COMPRESSION
BANDAGE (A6451,
A6452),SELF-ADHERENT  BANDAGE (A6453-A6455),CONFORMING
BANDAGE (A6442-A6447),
PADDING BANDAGE  (A6441):

Light compression bandages, self-adherent
bandages, and  conforming bandages are covered when
they are used to hold
wound cover  dressings in place over any wound type. 

Moderate or high
compression  bandages, conforming bandages, self-adherent bandages,
and
padding bandages  are covered when they are part of a multi-layer
compression bandage  system
used in the treatment of a venous stasis
ulcer.

All of these  bandages are noncovered when used for strains,
sprains, edema, or situations  other
than as a dressing for a
wound.

GRADIENT COMPRESSION  STOCKINGS/WRAPS (A6531, A6532,
A6545):

A gradient compression stocking  described by codes A6531 or
A6532 or a non-elastic gradient
compression wrap  described by code A6545 is
covered when it is used in the treatment of an  open
venous stasis
ulcer.

Codes A6531, A6532, and A6545 are noncovered  for the following
conditions: venous insufficiency
without stasis ulcers,  prevention of stasis
ulcers, prevention of the reoccurrence of stasis ulcers  that
have healed,
treatment of lymphedema in the absence of ulcers. In these  situations, since
there is
no ulcer, the stockings/wraps do not meet the  definition of a
surgical dressing. Gradient
compression stockings described  by codes A6530,
A6533-A6544, A6549 and surgical stockings
described by codes  A4490-A4510 are
noncovered for all indications because they do not meet  the
definition of a
surgical dressing.

A nonelastic binder for an  extremity (A4465) is
noncovered for all indications because it does not
meet  the definition of a
surgical dressing.


HCPCS CODES AND  MODIFIERS:
Added:  
A4490-A4510, A6545.

GRADIENT COMPRESSION WRAP  (A6545): [This is a Knee
length CircAid used in the treatment of
an  open venous stasis
ulcer.]

Coverage of a non-elastic gradient compression  wrap (A6545) is
limited to one per 6 months per
leg. Quantities exceeding  this amount will
be denied as not medically necessary. Refer to  Policy
Article for statement
concerning noncoverage if the ulcer has  healed.

Revised:   A6010-A6024,
A6196-A6199, A6203-A6215, A6219-A6248,  A6251-A6266,
A6407.
APPENDICES:
Revised:   Definitions of pressure ulcer
  stages.
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Added:   Reference
  to NPUAP guidelines for pressure ulcer staging.

Article for Surgical
  Dressings - Policy Article - Effective January 2009 (A23664)
Revision
  Effective Date:   01/01/2009 
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT
  RULES:
Clarified:   Allowance for HCPCS codes which use the term
“kit”.
Added:   Coverage statements for compression wraps (A6545).

The
  only products that may be billed with code A6545 (non-elastic compression wrap)
  are those
which have received a written Coding Verification Review from the
  Pricing, Data Analysis, and
Coding (PDAC) contractor and that are posted in
  the Product Classification List on the PDAC web
site. 

Added:  
Noncoverage statement for surgical stockings (A4490-A4510).
CODING
  GUIDELINES:
Added:   Requirement for PDAC Coding Verification Review for
  non-elastic compression
wraps (A6545).
Revised:   Changed SADMERC to
  PDAC.

==========================================================
The
  above all applies to coverage and coverage criteria created by the Social
  Security Act, Title XVIII,
section 1861(s)(5) Surgical
  Dressings.

Lymphedema compression bandages, garments and devices
  functionally meet the definition of the Social
Security Act, Title
  XVIII, section 1861(s)(8) Prosthetic Devices, and do not have to meet the
  coverage
criteria for surgical dressings.

The undersigned is
not  empowered to interpret Medicare statute or Medicare policy, but the above

statements based on my reading of the relevant statutes and CMS
policies  are my opinion, and have been
validated by eight U.S.
Medicare  Administrative Law Judges in ten separate Medicare
Appeals.

Robert Weiss,  M.S.
Lymphedema Patient Advocate
National
Lymphedema
  Network


-----------------------------------------------------------------

A
  revision to the LCD for Pneumatic Compression Devices (L11503) becomes
effective  on January 1,
2009 affecting the following
  states:

Connecticut
District of
  Columbia
Delaware
Massachusetts
Maryland
Maine
New
  Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode
  Island
Vermont

Pneumatic Compression Devices LCD L11503 
Revision
  Effective Date: 01/01/2009
INDICATIONS AND LIMITATIONS OF
COVERAGE:
Added:  Statement regarding appliances for the chest and
trunk.
HCPCS CODES AND  MODIFIERS:
Added: E0656 and E0657:

E0656
SEGMENTAL PNEUMATIC APPLIANCE  FOR USE WITH PNEUMATIC COMPRESSOR,
TRUNK
E0657 SEGMENTAL PNEUMATIC  APPLIANCE FOR USE WITH PNEUMATIC
COMPRESSOR,
CHEST

Article for  Pneumatic Compression Devices
- Policy Article - Effective January 2009  (A37216)
Revision Effective Date:
01/01/2009
CODING  GUIDELINES:
Changed: References from SADMERC to
PDAC.
References from  DMERC to DME
  MAC.

==================================================================

Physician’s Letter and Certificate
of  Medical Necessity

July 30, 2002

Mrs. Jane
  Patient 555-55-5555   DOB: 06/14/1942
Patient Diagnosis:  Chronic
Intractable  Lymphedema of the left lower extremity.  Her condition is
marked
by  severe 4+ edema of the left lower extremity, weeping wounds, and pain
affecting
mobility.  The tissue is hard and fibrotic.  There is no
discoloration.   Mrs. Patient recalled her
mother having difficulty
with lower  extremity edema, although she was never diagnosed with
Lymphedema.  Mrs. Patient began to experience lower extremity edema
about ten years ago,
after undergoing a hysterectomy, at which time
a lower abdominal,  hip-to-hip incision was made,
possibly
interrupting the inguinal  lymphatics.
Patient History: Mrs. Patient is also
diagnosed with diabetes,  and is Insulin dependent. 
Surgical History:
Hysterectomy, October 11, 1992.  Laproscopic Gall Bladder Surgery, February,
1972.
Complications  Resulting From Lymphedema: In 1996, Mrs. Patient
was treated with oral
antibiotics for cellulitis.  In January, 2002,
Mrs. Patient was  hospitalized for 14 days for cellulits,
and
weeping  wounds.

Previous Treatment:
Elevation    01/93 to present  no
  results
Exercise    01/93 to present  no results
Diuretics    01/93 to
  present  no results
Graduated Compression Stockings 01/93 to present  no
  results
MLD and Physical Therapy  03/01 to 04/01   minimal
  results
Compression Bandaging  03/01 to 04/01   minimal results
Unna
Boots  after January 2002 hospitalization for three months.  Dressing changed
weekly.  No
results.

At this time I am ordering a Bio
Compression  Gradient Sequential Compression Device to be
used at
55mmHg for 2 hours  BID for the remainder of her lifetime.  This device will
apply
gradient  sequential compression, on a thirty second cycle,
thus pushing the excess fluid  back into
the vascular system for
removal from the body.  She is also  to wear the OptiFlow SC during
compression therapy and for nighttime  compression. A Gradient pump is
required for Mrs.
Patient as she is  unable to tolerate the uniform
compression, and long cycle times, which is
delivered by the
standard sequential pumps.  If her condition is not  treated effectively, she is
at
risk of her condition worsening,  re-occurring cellulitis,
chronic weeping wounds, resulting in
possible  multiple
hospitalizations. 
Prognosis: Good with effective  treatment.

If you
have any questions, please contact me at
  702-555-5555.
Sincerely,


Dr. Joe Doctor, M.D.
What to do when
  your health plan denies your claim

If your health insurance company
  denies your claim and you believe the treatment should be
covered,
  first check your policy to see what benefits your plan provides. The Patient
  Bill of Rights
requires the policy to contain a description of the
  appeals process.

Be sure to send your letter of appeal by registered
mail  and have the receipt returned to the
address listed in the
  policy.

=================================================================

Insurance
  Information
INSURANCE COVERAGE TOOLS

I have compiled some healthcare
  insurance codes and healthcare conditions as relating to
Lymphedema
  coverage. PLEASE NOTE, These conditions, codes, rulings etc are different from

state to state, insurance plan to inusurance plan and are constantly
  changing. Proper
documentation and codes may be crucial in getting
  treatment covereage. Please check with your
insurer on the
requirements  and restrictions as it concerns lymphedema treatment. The codes
and
medical language should be an asset to your physician  or
therapist in  putting together the request
for treatment/therapy
coverage or  appealing a declination.

Conditions For Insurance Coverage
(taken from  various state medicare sources sources): This
coverage
policy was  developed to provide medical necessity guidelines for complex
decongestive
physiotherapy for lymphedema.

1. There is a
physician documented  diagnosis of lymphedema: and the physician specifically

orders CDP 2.  The patient is symptomatic for lymphedema, with
limitation of function related  to
self care, mobility and/or
safety. 3. The patient or patient  caregiver has the ability to understand
and comply with home care  continuation of treatment regimen. 4. The
services are being
performed  by a health care professional who has
received specialized training in this form  of
treatment.

ICD-9 diagnosis codes:

457.0 -  Post-mastectomy
Lymphedema Syndrome

457.1 - Other lymphedema

757.0  - Hereditary
edema of the legs (congenital lymphedema)

CPT  Codes:

97001 -
Physical therapy evaluation

97002 - Physical  therapy
re-evaluation

97003 - Occupational therapy  evaluation

97004 -
Occupational therapy re-evaluation

97110 -  Therapeutic procedure, one or
more areas, each 15 minutes: therapeutic exercises  to
develop
strength and endurance, range of motion and  flexibility

97140 - Manual
therapy techniques (e.g.  mobilization/manipulation, manual lymphatic drainage,

manual traction),  one or more regions, each 15 minutes

97535
- Self-care/home management  training (e.g., activities of daily living (ADL)
and
compensatory  training, meal preparation, safety procedures, and
instructions in use of  adaptive
equipment)direct one on one contact
by provider, each 15  minutes
Current Facts on Lymphedema in the United
States
Lymphedema is not  a widely discussed condition as many in the medical
field are actually quite
blind to its seriousness. That having been
said, the situation has begun to  improve as more and
more doctors
and health care professionals are  beginning to recognize the importance of
properly
treating this  condition. Though insurance companies have
been rather slow on the uptake,
lymphedema treatments are fast
becoming a respected field of medical  practice.

Every year millions of
American find themselves suffering from  lymphedema. Some of these
cases are primary in nature but the  overwhelming majority are acquired
after surgery or radiation
for  specific types of cancer; any type
of surgery that removes lymph nodes (like  breast cancer
surgery)
could result in lymphedema. Fortunately, doctors  are beginning to wise up and
send
afflicted patients to lymphedema  therapists so they can get
the help that they need.

Personal devices and  services
Businesses are
not required to provide personal devices (such as  wheelchairs) , individually

prescribed devices (such as eyeglasses or  hearing aids), or
services of a personal nature (such as
assistance in  eating,
toileting, or dressing), to customers with disabilities. A business may  choose

to provide services like this as a way to attract customers. For
  example, some large retail stores
provide electric carts for use by
  customers while shopping. Some fancy dress shops provide
assistance
for  a customer trying on clothes in the dressing room.

The ADA does not
  require these services; it leaves it up to the business to decide what services
  it
wants to provide. The ADA simply says a business should provide
the  same goods and services to
all of its customers, including
those with  disabilities.

--------------------------------

For
those readers  who have the military health insurance offered by Tricare For
Life and turn 65,
the coordination of the TFL and Medicare can
become confusing.  California Health Advocates
has issued an
informative Information sheet  for you. It can be found on
URL:
http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf

Bob
  Weiss

---------------------------------

The following website has
  been set up by America's Health Insurance Plans (AHIP) to help
consumers through the administrative maze of their healthcare provider.
It  provides great
common-sense information to help you with your
appeal of  denied medical treatment, and leads
you to state
insurance sites which  can help you file a complaint with your state if you get
no
satisfaction from your provider.
http://www.healthclaimappeals.org/

Bob
  Weiss
Robert Weiss, M.S.Lymphedema Patient
  Advocate

=====================================================================

To
  Lymphedema Therapists in CA, NV and HI:

There are two draft local
  coverage determinations (LCDs) of interest to the lymphedema
community  which are being made available by Palmetto GBA for comment.
Palmetto is the
Medicare Part A/B Jurisdiction 1 Contractor
responsible for issuing the  LCDs which govern
Medicare treatment
and billing policy, and which  affect reimbursements and allowable
treatment.

These two LCDs are for  Outpatient Physical Therapy (DLCD
#28689) and Outpatient
Occupational  Therapy (DLCD #28691). They are
available from the Palmetto web page or I can
send a .pdf file to
interested persons who wish to read and  comment.

The comment period is
from March 6, 2009 to April 20,  2009.

There will be a number of Open
Meetings to discuss these two LCDs  and a number of other draft
LCDs, but the meetings are only 2 hours  long and I would advise
submitting comments and
evidence before the  meetings so that they
are sure to be considered. Comments are sent  to:

Palmetto GBA, Attention
Part A J1 Medical Affairs, P.O.Box 1437,  Augusta, GA 30903-1437.
Email
Part
A comments  to J1A.Policy@Palmetto GBA.com
Palmetto GBA, Attention Part B J1
Medical  Affairs, P.O.Box 1476, Augusta, GA 30903-1476. Email Part
B
comments to  J1B.Policy@Palmetto GBA.com

The Part A and Part B LCDs are
the same, so I  don't know whether it matters which address the comments
are sent  to.

The open meetings scheduled are as
follows:

Hawaii: March 5,  2009 8-10AM @ The Queens Medical Center, 1301
Punchbowl Street, Conference
Room 203, Honolulu, HI
96813;

Nevada: March 12, 2009 9-11AM @ Clark  County Medical Association,
2590 E. Russell Road, Las
Vegas, NV  89120;

California: March
17, 2009 9-11AM @ Prostate Cancer Research  Institute, 5777 W. Century Blvd.,
Suite
800, Los Angeles, CA  90045.

I will be attending the
California meeting and submitting  comments. There is a registration process for
these
meetings on the  Palmetto web page.

There are a number
of issues I have noted which I plan  to comment on and make suggestions for
changes.
These issues  include:

A. Omission of a number of
medical diagnoses which are treated  with MLD but which are not included in
the list of diagnoses which  support treatment. These include codes for
hereditary LE of the lower limbs,
localized swelling, edema of the
eyelid, penis, breast and vulva, vericose  veins with edema, etc.
B.
Vasopneumatic Device Therapy is indicated for  lymphedema of the extremity, and
should probably
include lymphedema of  the torso now that a number
of pump manufacturers have body garments, and the
body garments have
separate HCPCS codes (but are not yet  covered).
C. Manual Decongestive
Therapy is described to "reduce lymphedema  of extremity" and should not be
limited to the extremity. See A  above.
D. Some clarification is
needed for billing for education on  exercise.
E. Fitting of compression
garments is not mentioned.
F. It is  not clear which protocol (if any) might
include education on wearing and care  for compression
garments,
specialized exercises, use of lasers,  etc.

I'm sure that the therapists
who read this note will have many  additional clarifications they'd like to have

made. Send them to me and  I'll try to include them in the document
I will be submitting at the Open  Meeting..

Robert Weiss,
MS
Lymphedema Patient
  Advocate

================================================================

Personal
devices  and services
Businesses are not required to provide personal devices
(such as  wheelchairs) , individually prescribed
devices (such as
eyeglasses or  hearing aids), or services of a personal nature (such as
assistance in eating,
toileting, or dressing), to customers with
disabilities. A business may  choose to provide services like this as a
way to attract customers. For  example, some large retail stores provide
electric carts for use by customers
while shopping. Some fancy dress
shops provide assistance for a  customer trying on clothes in the dressing
room.

The ADA does  not require these services; it leaves it up
to the business to decide what  services it wants to
provide. The
ADA simply says a business should  provide the same goods and services to all of
its
customers, including  those with
disabilities.

--------------------------------

For  those readers
who have the military health insurance offered by Tricare For Life  and turn 65,
the
coordination of the TFL and Medicare can become  confusing.
California Health Advocates has issued an
informative  Information
sheet for you. It can be found on URL:
http://www.cahealthadvocates.org/_pdf/facts/F-002-CHAFactSheet.pdf

Bob
  Weiss

---------------------------------

The following website has
  been set up by America's Health Insurance Plans (AHIP) to help consumers
through the administrative maze of their healthcare provider. It
provides  great common-sense information to
help you with your
appeal of denied  medical treatment, and leads you to state insurance sites
which can help
you file a complaint with your state if you get no
satisfaction from your  provider.
http://www.healthclaimappeals.org/

Bob
  Weiss
Robert Weiss, M.S.Lymphedema Patient
  Advocate

=================================================================

Current  Facts on Lymphedema in the
United States
Lymphedema is not a widely discussed  condition as many in the
medical field are actually
quite blind to its  seriousness. That
having been said, the situation has begun to improve as
more and
more doctors and health care professionals are beginning to  recognize the
importance of properly treating this condition. Though  insurance
companies have been
rather slow on the uptake, lymphedema
  treatments are fast becoming a respected field of
medical
  practice.

Every year millions of American find themselves suffering from
  lymphedema. Some of
these cases are primary in nature but the
  overwhelming majority are acquired after
surgery or radiation for
  specific types of cancer; any type of surgery that removes lymph
nodes  (like breast cancer surgery) could result in lymphedema.
Fortunately, doctors  are
beginning to wise up and send afflicted
patients to lymphedema  therapists so they can get
the help that
they
  need.

================================================================

Insurance
  Information
INSURANCE COVERAGE TOOLS

I have compiled some healthcare
  insurance codes and healthcare conditions as relating to Lymphedema
coverage. PLEASE NOTE, These conditions, codes, rulings etc are
different  from state to state, insurance
plan to inusurance plan
and are  constantly changing. Proper documentation and codes may be crucial in

getting treatment covereage. Please check with your insurer on the
  requirements and restrictions as it
concerns lymphedema treatment.
The  codes and medical language should be an asset to your physician  or
therapist in putting together the request for treatment/therapy coverage
or  appealing a declination.

Conditions For Insurance Coverage (taken
from  various state medicare sources sources): This coverage
policy
was  developed to provide medical necessity guidelines for complex decongestive
  physiotherapy for
lymphedema.

1. There is a physician
documented  diagnosis of lymphedema: and the physician specifically orders CDP
2.
The patient is symptomatic for lymphedema, with limitation of
function  related to self care, mobility and/or
safety. 3. The
patient or patient  caregiver has the ability to understand and comply with home
care
continuation of treatment regimen. 4. The services are being
performed by a  health care professional who
has received
specialized training in this  form of treatment.

ICD-9 diagnosis
codes:

457.0 - Post-mastectomy  Lymphedema Syndrome

457.1 - Other
lymphedema

757.0 - Hereditary  edema of the legs (congenital
lymphedema)

CPT Codes:

97001 -  Physical therapy
evaluation

97002 - Physical therapy  re-evaluation

97003 -
Occupational therapy evaluation

97004 -  Occupational therapy
re-evaluation

97110 - Therapeutic procedure, one or  more areas, each 15
minutes: therapeutic exercises to develop
strength  and endurance,
range of motion and flexibility

97140 - Manual therapy  techniques (e.g.
mobilization/manipulation, manual lymphatic drainage, manual
traction), one or more regions, each 15 minutes

97535 -
  Self-care/home management training (e.g., activities of daily living (ADL) and
  compensatory
training, meal preparation, safety procedures, and
  instructions in use of adaptive equipment)direct one on
one contact
by  provider, each 15 minutes

Surgical Dressings Billing  Instruction for
  HCPCS Code A6545

Recent revisions to the Local Coverage Determination
  (LCD) for Surgical Dressings and the related Policy
Article were
  published with an effective date of January 1, 2009. The Policy Article
revision  neglected to
include billing instructions for HCPCS Code
  A6545.

HCPCS Code Description A6545 Gradient compression wrap,
  non-elastic, below knee 30- 50 MM HG,
each

Similar to codes
  A6531 and A6532 (compression stockings) which are addressed in the Policy
  Article
Coding Guidelines section, HCPCS modifiers A1-A9 are not to
be  used with A6545.

When a gradient compression wrap, A6545, is used for
an  open venous stasis ulcer, the code must be billed
with the AW
modifier.  If there is no open ulcer, the AW modifier must not be used. Claims
for code  A6545
without an AW modifier will be denied as statutorily
  noncovered.

The right (RT) and left (LT) modifiers must also be used
with  this code. When the same code for bilateral
items (left and
right) is  billed on the same date of service, bill both items on the same claim
line using  LTRT
modifiers and 2 units of service.

These
guidelines will be  included in a future revision of the Surgical Dressings
medical  policy.

The only products that may be billed with code A6545
(non-elastic  compression wrap) are those which
have received a
written Coding  Verification Review from the Pricing, Data Analysis, and Coding
(PDAC)
contractor and that are posted in the Product Classification
List on the  PDAC Web site.

Suppliers should review the entire Surgical
Dressings LCD  and related Policy Article at http://www.
cignagovernmentservices.com/
  jc/coverage/LCDinfo.html
for additional guidance on the
  coverage, coding
and documentation
  requirements.
===================================
Comments to the above
  clarification:

These billing notes are based on coverage criteria for
  surgical dressings, covered by §1861(s)(5) of the
Social Security
Act.  They are based on the requirements for the surgical dressing benefit
category  that
requires there be an open debridable wound. It is my
contention,  disputed by Medicare Contractors, that
when used to
treat lymphedema, a  compression wrap is covered by the requirements of
§1861(s)(8)
prosthetic devices, and need not meet the coverage
criteria for surgical  dressings--a different benefit
category.

Furthermore, Medicare  policy is that HCPCS coding does
not determine coverage, and cannot be used to
establish or deny
coverage, so any argument that the A-group coding  means that it id denied in
any other
benefit group other than surgical  dressings is an invalid
statement, in my humble opinion.

The above  comments are not the opinions
of Medicare, and are not to be construed as  medical or legal
advice. They are my own opinions,  validated by  approximately 10
Administrative Law Judges in hearings in
a dozen  individual
Medicare hearings.

Robert Weiss, MS
Lymphedema Patient
  Advocate




-----------------------------------------------

Medicare
  has found a new method of denying covered compression therapy items without
  actually denying
them. Medicare Summary Notices are now noting
  "Medicare will process your first claim only. In the future
you
must  use a Medicare-Enrolled supplier and provide the supplier identification
number  on your claim."
and "Medicare cannot process this claim as
you were  previously notified that you must use a supplier who
has a
Medicare  supplier identification number."

If you plan to appeal the
denial of  compression bandage systems, garments or devices, it would be prudent

for you to purchase them from an enrolled supplier. Since these
items will  be denied, the supplier will ask
you to pay up front and
sign an  Advance Beneficiary Notice of Nonpayment (ABN) form signifying that you

understand that Medicare may not reimburse you for the purchase.
This gets  the supplier off the hook when
it is denied. The supplier
is then  obliged BY LAW to file the initial claim for you.

It seems that
Medicare  will process one claim and one claim only from a beneficiary who has
purchased a
medical item from a non-enrolled supplier or from the
manufacturer. In  this case the beneficiary files a
Patient's
Request for Medicare  Payment and the claim is processed by hand, instead of by
computer, and
takes a longer time to process.

The following
is a recent CMS  clarification on participating and non-participating
  suppliers:

"**Updated February 10, 2009- Clarification from January's
  DMEPOS Special Open Door Forum.
Participating Provider/Supplier and
  Accreditation requirements

Medicare enrolled participating providers and
  suppliers must always accept assignment. Assignment is an
agreement
  between beneficiaries, their providers/suppliers, and Medicare where the
  beneficiary authorizes
the provider/supplier to request direct Part
B  payment from Medicare for health care services, equipment,
and
  supplies. When the provider/supplier agrees to (or is required by law to)
accept  assignment from
Medicare, then the provider/supplier is
prohibited from  attempting to collect more than the applicable
Medicare deductible and  coinsurance amounts from the beneficiary, the
beneficiary's other insurance, or
anyone else. Providers/suppliers
that enter into a Medicare  Participating Physician or Supplier Agreement
(OMB No.0938-0373) agree  to accept the Medicare-approved amounts as
payment in full for all Part B
services and supplies. A beneficiary
should only pay the 20% co-pay (and  any remaining Part B deductible)
when
they receive their equipment or  supplies or when the equipment is
repaired.

A Medicare enrolled  non-participating provider/supplier, can
choose which services to accept  assignment
for (unless mandatory
assignment applies to the service;  e.g., for drugs or biologicals, ambulance
services,
etc.). Therefore,  the provider's/supplier's charges for
DME supplies may be higher than the  Medicare
approved amount and
the beneficiary has to pay the entire  charge for the Part B services and
supplies at the
time of service.  (NOTE: Medicare's limiting charge
does not apply to DME supplies.)

In  either case, participating and
non-participating, Medicare providers/suppliers  must bill Medicare on
behalf
of the beneficiary and must be accredited  by September 30, 2009 in order to
retain their Medicare
Part B billing  privileges."

The above
material is the undersigned's interpretation of  Medicare policy and procedures.
It is my opinion
only and is not  authorized or approved by
Medicare. This information is not to be used for  medical or legal
purposes, and is offered only as an aid in navigating  the Medicare
labyrinth.

Source:  Bob Weiss,  Lymphedema Patient Advocate,
  Medicare.gov
  website.

=======================================================
Letter
  to write for lymphedema day

Senator
  _________________
[Address]
[City, State, Zip]
Dear Senator
  _____________________:
I am a [lymphedema patient, breast cancer survivor,
  advocate and volunteer at the Carol Baldwin
Breast Care Center]. I
  would like to call your attention to Virginia House Joint Resolution No.
524 (please see enclosed copy). This resolution proclaims each March 6th
as  Lymphedema D-
Day in the State of Virginia.
It would be a
great step  forward for this "orphan disease" if each state and the United
States
government would proclaim March 6th of each year as
Lymphedema D-Day. As  one of your
constituents, I cannot stress
enough the impact that this  disease has on patients.
For further
information, you may contact the  National Lymphedema Network (800-541-3259 or

online at  www.lymphnet.org).
If I can be of any assistance in
promoting this  resolution, please do not hesitate to contact me.
I thank
you, in advance,  for your support.
Very truly yours,
[Your
  name]
=====================================================

There are
  several bills before the NY State Assembly and the NY State Senate regarding

lymphedema that would be of interest and concern to you.

What
the  bill(s) say in part are:  "To create awareness of lymphedema through
education  and to
promote and support the availability of quality
medical  treatment for all individuals at risk or
affected by
  lymphedema".

The bills that are to be voted on are A5320 (NY Assembly
  bill), S629 (NY Senate bill) and A5321
(NY State Assembly bill),
S2585  (NY State Senate bill.

To read all of the information on these
important  bills regarding lymphedema go to www.ny.gov
which is the
home page for  the State of New York.

On the right side you will find a
section called  LEGISLATIVE and under that heading you will find
New
York State  Assembly and New York State Senate.  By clicking onto those headings
you will
find on the left side Bills and Laws where you can enter
the bill  number to read what it entails,
they are quite detailed. 
The bills in  both the Assembly and the Senate are cross-referenced so
you
can look  at both in as much detail as you like by checking boxes of what
information you  want
to review.

Also on the left side you
will find Assembly and  Senate and you can click onto those and it will
give you a list of your  representatives for your area and you can write
to them if you like and let
them know how you feel about the bill(s)
that are to be voted on.  You can  search by your zip code
to find
the appropriate members for your area  and their email addresses to write to
them if you
want.

If you  are wanting to write and give your
support, non-support or comments and feelings  on the
particular
bill the Assembly Members and Senate Members will be  better equipped to vote on

that bill.

It would also be good if  you wanted to email
Senator Thomas K. Duane at duane@senate.state.ny.
us  who chairs the
health committee and let him know how you feel on these  particular
bills.

Of course, it is your decision if you want to email  these people
to let them know how you feel
about these important bills
  concerning lymphedema legislation for the State of New York.  You
MUST  be a New York State resident to have an effect to comment on these
bills that  are now in
process so this post is meant for NY
residents only however  anyone can look at them if they want
to.

This is meant to be  informational only and is not an
endorsement by Lymphland or it's
management, these decisions are for
NY State residents to make through  their legislative process.







The
following is  a summary of a Wall Street Journal article on a subject of
potential impact to  all
lymphedema patients on Medicare or
Medicaid. One of the impacts of  this upcoming competitive
bidding
program for durable medical  equipment, prosthetics, orthotics and supplies
(DMEPOS) is that
you wil  have to obtain DMEPOS (compression
bandages, garments, supplies, devices) from a  small
number of
selected enrolled Suppliers. This might represent a  major business impact for
the specialized
manufacturers and suppliers  of lymphedema treatment
items, and preclude any attempt for the
patient/Beneficiary to
obtain reimbursement for these items.

I urge  you all to call your
Congressional legislators and ask them whether the small  savings to Medicare

are worth the major reduction in access to the  items you use daily
in the treatment of your
lymphedema. Ask your  DMEPOS Supplier about
the impact of this program on the availability of your
lymphedema
treatment items.

Bob Weiss


Thursday, March 19,
  2009

Medicare Wall Street Journal Examines Potential Effects of Medicare
  Competitive Bidding Program
for Durable Medical
  Equipment


The Wall Street Journal on Thursday examined "Medicare's
  second attempt at putting a competitive
bidding program in place"
for  durable medical equipment and the potential effects on access to services

for beneficiaries (Martinez, Wall Street Journal, 3/19). CMS
attempted to  implement the program last
year, but a law enacted
last summer delayed  the initiative and required the agency to repeat the
initial
bidding  process. In February, CMS announced plans to
implement the program on April 19  (Kaiser
Daily Health Policy
Report, 2/23).

According to the  Journal, the program likely will reduce
costs for Medicare and beneficiaries,  who pay
20% of the cost of
DME, but suppliers and some patient advocacy  groups have raised concerns that

"it also may mean new hassles for  patients." In addition, some
Medicare beneficiaries "worry about no
longer being able to do
business with providers they have come to rely on  for lifesaving equipment,"
the
Journal reports.

Tyler Wilson --  president of American
Association for Homecare, which represents DME suppliers  --
said,
"Competitive bidding is going to eliminate 90% of home care  providers," adding,
"The result is
going to be lower quality and lower  access to care
for seniors and people with disabilities." In addition,
AAH
officials said that the program will reduce costs for Medicare by only  a small
amount.
Expenditures for DME will account for less than 2% of  the
estimated $500 billion budget for Medicare
this year, they
  said.

Laurence Wilson, director of the chronic care policy group at CMS,
  said that the program will provide
"value to Medicare and its
  beneficiaries, as well as taxpayers" and ensure that beneficiaries have access

to needed DME. CMS officials also said that the program would reduce
  costs for Medicare by $1
billion annually (Wall Street Journal,
  3/19).

---------------------------

The following clarification
  refers to supplies used in conjunction with previously obtained DME, and
how to document the medical necessity of the supplies. It is my opinion
  that this concept applies
equally to supplies necessary for the use
  with prosthetic devices such as Reid Sleeves, Circaids, etc.
These
  supplies, such as finger bandages, gauze sleeves, localized foam pads, etc are
  coverable, in my
opinion, and should be claimed by Medicare
patients.  Make sure that you have a physician's
prescription for
use in the  treatment of lymphedema.

Bob Weiss
Lymphedema Patient
  Advocate

April 21, 2009

Supplies and Accessories Used With
  Beneficiary Owned Equipment
April 2009 Clarification


The DME MACs
  recently published an article addressing documentation requirements for
supplies  and
accessories used with beneficiary owned equipment. 
This article  only addressed equipment that was
not paid for by
Medicare FFS - i.e.,  only equipment that was paid by other insurance or by the

beneficiary.  For supplies and accessories used with that equipment,
all of the following  information
must be submitted with the initial
claim in Item 19 on the  CMS-1500 claim form or in the NTE segment
for electronic claims:   

* HCPCS code of base equipment;
and,
* A notation that this  equipment is beneficiary-owned; and,
* Date
the patient obtained the  equipment.

Claims for supplies and accessories
must include all three  pieces of information listed above.  Claims
lacking any one of the  above elements will be denied for missing
information.

Medicare requires  that supplies and accessories only be
provided for equipment that meets the  existing
coverage criteria
for the base item.  In addition, if the  supply or accessory has additional,
separate
criteria, these must also  be met.  In the event of a
documentation request from the contractor or a
redetermination
request, suppliers should provide information justifying  the medical necessity
for the
base item and the supplies and/or  accessories.  Refer to
the applicable Local Coverage Determination
(s)  and related Policy
Article(s) for information on the relevant coverage,  documentation and coding

requirements.

-------------------------------------------------------------------------------------------
July
  Quarterly Update for 2009 for Durable Medical Equipment, Prosthetics,
Orthotics,  and Supplies
(DMEPOS)
MLN Matters Number:
MM6511

HCPCS codes  A6545, E0656, E0657 and L0113 were added to the HCPCS
file effective January 1,
2009. The fee schedule amounts for these
HCPCS codes are established as  part of this update and are
effective for claims with dates of service  on or after January 1, 2009.
These items were paid on a local
fee  schedule basis prior to
implementation of the fee schedule amounts established  in accordance with
this update. Claims for the above codes with dates  of service on or
after January 1, 2009 that have
already been processed  will not be
adjusted to reflect the newly established fees if they are  resubmitted
for adjustment.

As part of this update CMS is adding  the AW
modifier to the fee schedule file for HCPCS code
A6545 Gradient
  Compression Wrap, Non-Elastic, Below Knee, 30-50 MM HG, Each. Code A6545
is covered when it is used in the treatment of an open venous stasis
ulcer.  Currently, code A6545 is
noncovered for the following
  conditions:

Venous insufficiency without stasis ulcers, prevention of
  stasis ulcers, prevention of the reoccurrence of
stasis ulcers that
  have healed, and treatment of lymphedema in the absence of ulcers. In these
situations, since an ulcer is not present, the gradient compression
wraps  do not meet the definition of a
surgical dressing. Suppliers
are  advised that when the non-elastic gradient compression wrap code
A6545
  is used in the treatment of an open venous stasis ulcer, it must be billed with
  the AW modifier.
Claims for code A6545 that do not meet the covered
  indications should be billed without the AW
modifier and as such,
will  be denied as non-covered.

For Information on Lymphedema-related
  items:
A6545 is the CircAid JuxtaFit
E0656 is Segmental Pneumatic
  Appliance for the Trunk
E0657 is Segmental Pneumatic Appliance for the
  Chest

Note that the CircAid is not approved for the treatment of
  lymphedema in the absence of an open
wound since it does not meet
the  coverage requirements of a “secondary surgical dressing” benefit.
This
  is not to say that it could not be held to meet the coverage requirements of a
  different benefit
category, such as “prosthetic
devices”.

Bob
  Weiss


-------------------------------------------

please make
  the following correction.
A6545 code covers the T3M only, not the Juxta-Fit
  as stated.
T3M garment is specifically for Venous Disease not
  Lymphedema.
If have any questions, please feel free to contact me.
Thank
  you for your attention to this matter.

Ingrid Adams
Director of
  Sales
CircAid Medical Products
Phone: 800-247-2243 ext 233
Fax:
  858-576-3555


=====================================

If you are
  associated with a wound clinic you may wish to comment on this upcoming policy
  change.

Bob Weiss

Healthcare Common Procedure Coding System
  (HCPCS) Coding Decision and Preliminary Medicare
Payment Decision
for  Negative Pressure Wound Therapy (NPWT) Devices

CMS' preliminary
  Healthcare Common Procedure Coding System (HCPCS) coding decision and
preliminary
Medicare Payment decision for negative pressure wound therapy  (NPWT) devices is
now
published in the July 9, 2009 NPWT Public Meeting  Agenda. This
public meeting affords stakeholders
an opportunity to  provide input
concerning the preliminary decision.
The Medicare Improvements  for Patients
and Providers Act of 2008 required the Secretary to
evaluate
existing HCPCS codes for NPWT devices to ensure accurate reporting  and billing
for the
items and services under such codes; use an  existing
process for the consideration of coding changes:
and consider  all
relevant studies andinformation furnished through the process.
CMS  partnered
with Agency of Healthcare Research and Quality (AHRQ) to commission a  review of

NPWT devices to ensure all relevant studies and information  on NPWT
were captured. ECRI Institute
solicited information from
  stakeholders and searched literature in conducting this review. A draft report

of their findings was published for comment in April 2009. After
  analysis of comments received, ECRI
concluded that the available
  evidence does not support significant therapeutic distinction of a NPWT
system or component of a system. The report informed CMS' HCPCS
workgroup's  decision. The final
report will be publicly available
no later than  June 10, 2009 on AHRQ's homepage for the Technology
Assessment Program  at http://www.ahrq. gov/clinic/  techix.htm.


============================

The
  Durable Medical Equipment Medicare Administrative Contractor Jurisdiction A
(DME  MAC A)
NHIC, Corp. has announced a change in Medicare billing
policy in  a Surgical Dressing LCD Article

Surgical Dressings 
Policy
Article 
Revision Effective Date:  01/01/2009 (September
Publication)
CODING  GUIDELINES:
Added:  A6545 to list of codes requiring
the AW  modifier.
Added:  A6545 to list of codes requiring the RT and/or LT
  modifier(s).
Revised:  RT/LT modifier instructions.

The change may be
  found in Article for Surgical Dressings - Policy Article - Effective January
  2009
(September 2009 Publication) (A23664)

Abstracted
  information of possible interest to the lymphedema/wound care community is as
  follows:

A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50
  MM
HG, EACH

GRADIENT COMPRESSION STOCKINGS/WRAPS (A6531,
A6532,  A6545):

A gradient compression stocking described by codes A6531
or A6532  or a non-elastic gradient
compression wrap described by code A6545
is covered  when it is used in the treatment of an open
venous stasis
ulcer.

Codes  A6531, A6532, and A6545 are noncovered for the following
conditions: venous  insufficiency
without stasis ulcers, prevention of stasis
ulcers, prevention  of the reoccurrence of stasis ulcers that
have healed,
treatment of  lymphedema in the absence of ulcers. In these situations, since
there is
no  ulcer, the stockings/wraps do not meet the definition of a
surgical dressing.  Gradient
compression stockings described by codes A6530,
A6533-A6544, A6549  and surgical stockings
described by codes A4490-A4510 are
noncovered for all  indications because they do not meet the
definition of a
surgical  dressing.

A nonelastic binder for an extremity (A4465) is
noncovered for  all indications because it does not
meet the definition of a
surgical  dressing.

The only products that may be billed with code A6545
  (non-elastic compression wrap) are those
which have received a written
Coding  Verification Review from the Pricing, Data Analysis, and
Coding
(PDAC)  contractor and that are posted in the Product Classification List on the
PDAC  web
site. 

When tape codes A4450 and A4452 are used
with  surgical dressings, they must be billed with the
AW modifier (in
addition to  the appropriate A1-A9 modifier). When gradient compression
stocking
codes  A6531 and A6532 or the gradient compression wrap code A6545
are used for an open  venous
stasis ulcer, they must be billed with the AW
modifier (but not an  A1-A9 modifier). For this policy,
codes A4450, A4452,
A6531, and A6532, and  A6545 are the only codes for which the AW modifier
may
be used.

The RT  and/or LT modifiers must be used with codes A6531,
A6532, and A6545 for  gradient
compression stockings and wraps. When the same
code for bilateral  items (left and right) is billed
on the same date of
service, bill both items  on the same claim line using RTLT modifiers and 2
units
of service. Claims  billed without modifiers RT and/or LT will be
rejected as incorrect  coding.

GRADIENT COMPRESSION WRAP
(A6545):

Coverage of a  non-elastic gradient compression wrap (A6545) is
limited to one per 6 months  per
leg. Quantities exceeding this amount will
be denied as not medically  necessary. Refer to Policy Article
for
statement concerning noncoverage  if the ulcer has healed.

Revision
History Explanation
Revision  Effective Date: 01/01/2009 (September
Publication)
CODING  GUIDELINES:
Added: A6545 to list of codes requiring
the AW  modifier.
Added: A6545 to list of codes requiring the RT and/or LT
  modifier(s). 
Revised: RT/LT modifier instructions.

Revision
  Effective Date: 01/01/2009 
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT
  RULES:
Clarified: Allowance for HCPCS codes which use the term
“kit”.
Added: Coverage statements for compression wraps (A6545).
Added:
  Noncoverage statement for surgical stockings (A4490-A4510).
CODING
  GUIDELINES:
Added: Requirement for PDAC Coding Verification Review for
  non-elastic compression wraps
(A6545).
Revised: Changed SADMERC to
  PDAC.

------

I found another article you may be interested in
  reading that came from Center for Medicare and
Medicaid
  Services...."Medicare's New Requirements For Durable Medical Equipment,
  Prothestics,
Orthotics, And Supplies".

This may be accessed
at  the following:

http://www.medicare.gov/publications/pubs/pdf/11437.pdf

--------------------------

I
  came across an article from the National Cancer Institute that you might be
  interested in reading...."
Weight Lifting Does Not Exacerbate And
May  Improve Lymphedema Symptoms After Breast
Cancer".

You
can access  the article at:

http://www.cancer.gov.clinicaltrials/results/lymphedema0909



==================================

The
  above Local Coverage Determination LCD) and its accompanying coverage article
  represent the
Medicare basis for denial of compression bandages,
  garments and sevices.  In this writer's humble
opinion, validated
by  several Administrative Law Judges, this LCD applies only to the coverage
  criteria
for the Medicare benefit category of SURGICAL DRESSINGS,
which  by statute and policy, covers
only materials used in the
treatment of  open wounds, incisions, venous ulcers, etc. They derive
ultimately
from  the Social Security Act section 1861(s)(5), surgical dressings. As a
matter of  law, the
criteria for coverage under one benefit category
cannot be  used to deny coverage of an item which falls
into the
definition of a  different benefit category.

When used in the compression
treatment of  lymphedema these materials (compression bandages,
garments and sevices)  meet the definition of PROSTHETIC DEVICES, and
are therefore covered by
Medicare. They cannot be denied by invoking
the coverage criteria for  surgical dressings as
documented in the
"LCD for Surgical Dressings  (L11471)" and its "Article for Surgical Dressings

Policy Article  A23664)".

Robert Weiss, MS
Lymphedema
Patient Advocate
National  Lymphedema Network

LymphActivist@aol.com

-----


Plaintiffs
win suit  to keep their Social Security benefits even if they reject Medicare 

Constitutional attorney Kent Masterson Brown has won an important legal
  victory on behalf of three
plaintiffs — former Congressman Dick
Armey,  Brian Hall and John Kraus — who sued to keep their
Social
Security  benefits after they withdrew from Medicare Part A, preferring to keep
their  private
healthcare coverage. The Department of Health and
Human  Services had sought to dismiss the suit,
arguing that the
plaintiffs  had not exhausted their administrative remedies. But U.S. District
Judge
Rosemary Collyer, noting that one plaintiff has waited three
years for an  administrative hearing without
action, ruled that the
plaintiffs had  standing to contest their claim on the merits of the case. On
October
5, 2009, the Wall Street Journal published an editorial
regarding the  judge’s decision, saying, “This
(case) could be a big
deal”.

The  plaintiffs argued that as they had paid a lifetime of taxes
into Social  Security, they should not be
denied benefits simply
because they are  willing to pay for their own medical care. In 1993, under the

Clinton  administration, Social Security’s Program Operations Manual
System (POMS) was  changed
to state that seniors who withdraw from
Medicare A also  surrender their Social Security benefits. You
can’t
have one without  the other. But POMS is not in the statute or regulations that
govern  Medicare.

According to the Wall Street Journal, the response of
the  Department of HHS speaks volumes about
the contradiction
between the  Obama administration’s principles and its rhetoric: “President
Obama
says his plan for a ‘public option’ wouldn't be coercive,
saying that ‘If  you like your health-care plan,
you keep your
health-care plan. Nobody  is going to force you to leave your health-care plan.’
But here
is a  case where federal bureaucrats are using their power
to force Medicare on  seniors. Let's hope the
courts restore a
genuine right to  choose.”
Freedom of healthcare choice is a big deal. 
Should Medicare become  insolvent, as it is widely
expected to do,
seniors may not be able to  opt out in order to preserve their health insurance.

Coercion in your  choice of healthcare is a key part of the current
healthcare  legislation.

October 20, 2009

Plaintiffs win suit to
keep their  Social Security benefits even if they reject Medicare 

Constitutional  attorney Kent Masterson Brown has won an important legal
victory on behalf of  three
plaintiffs — former Congressman Dick
Armey, Brian Hall and John  Kraus — who sued to keep their
Social
Security benefits after they  withdrew from Medicare Part A, preferring to keep
their private
healthcare coverage. The Department of Health and
Human Services had sought  to dismiss the suit,
arguing that the
plaintiffs had not exhausted  their administrative remedies. But U.S. District
Judge
Rosemary  Collyer, noting that one plaintiff has waited three
years for an administrative  hearing without
action, ruled that the
plaintiffs had standing to  contest their claim on the merits of the case. On
October
5, 2009, the  Wall Street Journal published an editorial
regarding the judge’s decision,  saying, “This
(case) could be a big
deal”.

The plaintiffs argued  that as they had paid a lifetime of taxes
into Social Security, they should not  be
denied benefits simply
because they are willing to pay for their own  medical care. In 1993, under the

Clinton administration, Social  Security’s Program Operations Manual
System (POMS) was changed
to state  that seniors who withdraw from
Medicare A also surrender their Social Security  benefits. You
can’t
have one without the other. But POMS is not in the  statute or regulations that
govern Medicare.

According to the Wall Street  Journal, the response of
the Department of HHS speaks volumes about
the  contradiction
between the Obama administration’s principles and its rhetoric: “President Obama

says his plan for a ‘public option’ wouldn't be  coercive, saying
that ‘If you like your health-care plan,
you keep your  health-care
plan. Nobody is going to force you to leave your health-care plan.’ But here
is a case where federal bureaucrats are using their power to  force
Medicare on seniors. Let's hope the
courts restore a genuine  right
to choose.”
Freedom of healthcare choice is a big deal.  Should  Medicare
become insolvent, as it is widely
expected to do, seniors may  not
be able to opt out in order to preserve their health insurance.
Coercion in your choice of healthcare is a key part of the current
  healthcare legislation.

October 20, 2009


Plaintiffs win suit
  to keep their Social Security benefits even if they reject Medicare 

Constitutional attorney Kent Masterson Brown has won an important legal
  victory on behalf of three
plaintiffs — former Congressman Dick
Armey,  Brian Hall and John Kraus — who sued to keep their
Social
Security  benefits after they withdrew from Medicare Part A, preferring to keep
their  private
healthcare coverage. The Department of Health and
Human  Services had sought to dismiss the suit,
arguing that the
plaintiffs  had not exhausted their administrative remedies. But U.S. District
Judge
Rosemary Collyer, noting that one plaintiff has waited three
years for an  administrative hearing without
action, ruled that the
plaintiffs had  standing to contest their claim on the merits of the case. On
October
5, 2009, the Wall Street Journal published an editorial
regarding the  judge’s decision, saying, “This
(case) could be a big
deal”.

The  plaintiffs argued that as they had paid a lifetime of taxes
into Social  Security, they should not be
denied benefits simply
because they are  willing to pay for their own medical care. In 1993, under the

Clinton  administration, Social Security’s Program Operations Manual
System (POMS) was  changed
to state that seniors who withdraw from
Medicare A also  surrender their Social Security benefits. You
can’t
have one without  the other. But POMS is not in the statute or regulations that
govern  Medicare.

According to the Wall Street Journal, the response of
the  Department of HHS speaks volumes about
the contradiction
between the  Obama administration’s principles and its rhetoric: “President
Obama
says his plan for a ‘public option’ wouldn't be coercive,
saying that ‘If  you like your health-care plan,
you keep your
health-care plan. Nobody  is going to force you to leave your health-care plan.’
But here
is a  case where federal bureaucrats are using their power
to force Medicare on  seniors. Let's hope the
courts restore a
genuine right to  choose.”
Freedom of healthcare choice is a big deal. 
Should Medicare become  insolvent, as it is widely
expected to do,
seniors may not be able to  opt out in order to preserve their health insurance.

Coercion in your  choice of healthcare is a key part of the current
healthcare  legislation.

October 20, 2009


http://www.healthfreedom.net/index.php?option=com_content&task=view&id=922&Itemid=1

------

The amount in
  Controversy minimums to be able to bring an appeal to a Medicare Administrative
  Law
Judge (ALJ) hearing has been raised from $120.00 in 2009 to
$130.00  in 2010. What that means is
that a disputed item
(compression bandage  kit or compression garment) must cost more than $162.50

before you can  have an ALJ hearing since the disputed amount, which
is the purchase price minus  the
20% co-pay, must be more than
$130.00). Otherwise don't bother  filing a claim or an appeal. You
need two garments anyway so that one  can be worn while the other
dries.

Bob Weiss

Reference [Federal  Register: September 25, 2009
(Volume 74, Number 185)]
[Notices]              
[Page
48976-48977]

DEPARTMENT OF HEALTH AND HUMAN  SERVICES

Centers for
Medicare & Medicaid  Services

[CMS-4141-N]


Medicare
Program; Medicare Appeals;  Adjustment to the Amount in
Controversy Threshold
Amounts for Calendar Year  2010

AGENCY: Centers for Medicare &
Medicaid Services (CMS),  HHS.

----

How can a Medicare beneficiary
find out if their  supplier does not meet the new requirements?

Medicare
beneficiaries  should ask their suppliers if they meet the new Medicare
requirements so they
can continue to get their suppliers covered by
Medicare and to avoid  any interruption in their services.

What should a
Medicare beneficiary do  if their supplier does not meet the new
requirements?

If a beneficiary's  supplier isn't going to meet the new
requirements, they will have to look for  another
Medicare-approved
supplier in order for Medicare to pay for  their equipment and
supplies.

How does a beneficiary find a new Medicare
  supplier?

Beneficiaries should ask their current supplier if they are
  working with another supplier who can help
the beneficiary. If the
  beneficiary's current supplier can't help, the beneficiary should call
1-800-
MEDICARE (1-800-633-4227) and a customer service
representative can help  them find a new
supplier. TTY users should
call 1-877-486-2048. Or,  visit www.medicare.gov and select "Find
Suppliers of Medical Equipment  in Your Area." In order to ensure
Medicare payment, beneficiaries
should always ask any new supplier
they contact if they are still approved  by Medicare to provide
covered medical equipment and  supplies.

What if a beneficiary
doesn't want to change  suppliers?

Starting October 1, 2009, all
suppliers must meet the new  Medicare requirements in order to be paid
by
Medicare. If a supplier  hasn't met these requirements and a beneficiary
continues to get supplies
from the supplier, the beneficiary may
have to pay the full cost for the  supplies.

What should a beneficiary do
if they have oxygen and their  current supplier told them that they are
removing their equipment after  October 1, 2009?

A beneficiary
should call 1-800-MEDICARE  (1-800-633-4227) and a customer service
representative can help them  find a new supplier. TTY users should call
1-877-486-2048.

What will  happen with equipment in a beneficiary's home
if they have to change  suppliers?

A beneficiary's current supplier
should make arrangements to  remove the equipment after the
beneficiary has received replacement  equipment from their new
supplier.

What if my new supplier does not  provide a beneficiary with
the supplies their doctor originally
ordered?

The new
supplier has an obligation to provide a beneficiary  with the supplies that
their physician orders
for them. If a  beneficiary has any concerns,
they should contact their doctor to discuss  them.

What if a
beneficiary's existing supplier is the only one in their  town and is not
Medicare approved?

A beneficiary's existing supplier may  choose not to
participate. Beneficiaries should call 1-800-
MEDICARE
  (1-800-633-4227) and a customer service representative can help them find a new

supplier in their area. TTY users should call
  1-877-486-2048.

What can a beneficiary do if they have a complaint about
  their DME supplier?

CMS can assist a beneficiary who has a complaint
  about their DME supplier. Beneficiaries should call
1-800-MEDICARE
  (1-800-633-4227) and give the customer service representative the name and
address of their supplier and the nature of their complaint. Someone
from  CMS and/or the supplier will
get back to the beneficiary as
soon as  possible.

Will a beneficiary's prescription drugs be affected by
the new  requirements?

A beneficiary's prescription drugs are not
affected by the  new requirements, only the medical supplies
that
they are  receiving.

Why can't a beneficiary continue to go to their
pharmacy to  get their diabetic supplies?

If a beneficiary's pharmacy
hasn't met  Medicare's new requirements, they won't be able be able to
provide
the  beneficiary's diabetic supplies after October 1, 2009. To find a pharmacy
that  can provide
diabetic supplies or a mail order supplier, a
beneficiary  should visit www.medicare.gov and select
"Find
Suppliers of Medicare  Equipment in Your Area." Or, call 1-800-MEDICARE
(1-800-633-
4227). TTY  users should call 1-877-486-2048.

Must
a non-accredited supplier use an  Advance Beneficiary Notice (ABN) before
selling DMEPOS
items to a  beneficiary?

Non-accredited
suppliers should use an Advance Beneficiary  Notice (ABN) before providing a
Medicare beneficiary with an item or  service to alert the beneficiary
to the fact that the supplier is non-
accredited and unable to bill
Medicare for the item – so the beneficiary  knows they will have to pay the
full cost for the item or service. The  only exception to this rule is
when a non-accredited supplier has
posted clearly visible signs
(undisputed by the beneficiary) at the  supplier's place of business that
informs beneficiaries that it is not  accredited by Medicare and cannot
bill Medicare, so the beneficiary
knows they must pay for the item
or service.

Is a beneficiary  protected if they purchase a supply from a
non-accredited supplier?

There  are retail outlets and pharmacies that
furnish DMEPOS items to cash and carry  customers which
do not meet
the new Medicare requirements. Therefore  beneficiaries should always ask if the
supplier
meets the new Medicare  requirements to make sure Medicare
will pay for their supplies. Medicare
"may" reimburse a beneficiary
for a one-time only supply and give notice to  the beneficiary that any
future bills will not be reimbursed. The  supplier locator tool on
www.medicare.gov is available to
beneficiaries  to locate enrolled
DMEPOS suppliers that service their area.

Can a  non-accredited pharmacy
that provides DME supplies to a dual eligible  beneficiary be
reimbursed by Medicaid?

As long as the pharmacy  is a Medicaid
provider, the pharmacy may be reimbursed by Medicaid for a
Medicaid-covered item.

Will a beneficiary's Medicare premium
  increase because the suppliers now need to be
accredited/obtain a
  surety bond?

A beneficiary's Medicare premium is not affected by these
  new Medicare requirements.

-----

NHIC, Corp., Medicare DME MAC
  Jurisdiction A has posted the results of a review of claims for a
lymphedema pump. The review revealed that over half of the claims for
  lymphedema pumps have been
rejected or down-graded. An analysis of
the  reasons for rejection can help future requests for these
devices. The  results point up the importance of having a well-written
Certificate of Medical  Necessity
(CMN) DME MAC Form 04.04B /CMS
Form 846  Pneumatic  Compression Devices signed by the
patient's
physician.

The CMN  must show that the use of a multichambered sequential
pressure pneumatic  compressor with
calibrated gradient pressure is
medically necessary for  the treatment of the patient's lymphedema, that
other "more  conservative" protocols such as elevation, compression and
exercise have been  tried and
have not been successful, that there
is a medical reason for  this patient to have a pump because of
difficulty in performing CDT at  home. Note that 14% of the claims were
denied on the basis that
"equipment is the same or similar to
equipment already in use" even though  Medicare frequently
requires
a failed trial of non-segmented pumps  before a more appropriate model is
approved [Ref.
LCD  L11503].

Physicians must be meticulous
and complete in writing their  prescription, including the diagnostic code
for lymphedema, the  physician's name address and NPI, and as full a
description of the type of pump
that is medically indicated,
including the designation of the kinds of  garments required (e.g. full sleeve
or
legging, upper or lower body  segment, etc.)

Bob
Weiss


Results of Widespread Prepayment  Review of Claims for HCPCS
Code E0652
(Pneumatic Compressor, Segmental Home  Model with Calibrated
Gradient Pressure)

Posted October 30,  2009

The DME MAC A Medical
Review Department concluded a widespread  review of HCPCS code
E0652
from June 2009 through September  2009.

The results of the quarterly
review of the claims from June 1, 2009  through September 30, 2009
identified eight hundred sixty-five (865)  claims of which two hundred
sixty-three (263) were denied.
This  resulted in an overall Charge
Denial Rate of 54.00%.

The following are  the top five (5) reasons for
denial:
o The equipment is considered not  reasonable and necessary (69
claims)
o The prescription is incomplete (46  claims)
o Duplicate claims
(43 claims)
o Equipment is same or similar to  equipment already in use (38
claims)
o Claim not payable under Jurisdiction A  (e.g., claim submitted to
incorrect contractor) (16 claims)

The other  reasons for denial are as
follows: (51 claims)
o Patient eligibility (e.g.,  patient cannot be
identified as Medicare insured; beneficiary not covered by
Medicare;
or beneficiary covered by another plan or HMO, etc.)
o Date of  death
precedes date of service
o Missing or incomplete supplier  information
o
Claim contains incomplete or invalid information (e.g., missing  or incomplete
diagnosis or condition)
o No response to medical records  request
o The
equipment was provided while the patient is in the nursing  home
o Lifetime
benefit maximum for equipment has been reached

The  Local Coverage
Determination (LCD) for Pneumatic Compression Devices (L11503)  states in
part:

Pneumatic Compression Devices are only covered  for the
treatment of lymphedema or for the
treatment of chronic venous
  insufficiency with venous stasis ulcers, prescribed by a physician and
determination by the physician of the medical necessity which must
include  the following:
o The patient's diagnosis and prognosis;
o
Symptoms and  objective findings, including measurements which establish the
severity of the
condition;
o The reason the device is required,
including the  treatments which have been tried and failed; and
o The
clinical response to  an initial treatment with the device. The clinical
response includes the change
in pre-treatment measurements, ability
to tolerate the treatment  session and parameters and ability of
the
patient (or caregivers) to  apply the device for continued use in the
home.

The medical documentation  submitted for five hundred thirty-four
(534) claims supported the medical
necessity for a lower level item,
thus the services were down-coded to the  least costly alternative.

The
Pneumatic Compression Devices (L11503) LCD  states:

“When a segmented
device with manual control of the pressure in  each chamber (E0652) is ordered

and provided, payment will be based on  the allowance for the least
costly medically appropriate
alternative,  E0651, unless there is
clear documentation of medical necessity in the  individual case. Full
payment
for code E0652 will be made only when  there is documentation that the
individual has unique
characteristics  that prevent satisfactory
pneumatic compression treatment using a non-segmented
device (E0650)
with a segmented appliance/sleeve (E0671 - E0673) or a  segmented device without

manual control of the pressure chamber  (E0651).”

For any
item to be covered by Medicare, it must:
o Be  eligible for a defined
Medicare benefit category;
o Be reasonable and  necessary for the diagnosis
or treatment of illness or injury or to improve the
functioning of a
malformed body member; and
o Meet all other  applicable Medicare statutory
and regulatory requirements.

Suppliers are  reminded that documentation
must be made available to the DME MAC upon  request.
Reference the following
under the Documentation Requirements section  in the Pneumatic Compression
Devices (L11503) LCD, which states in  part:

“Section 1833 (e) of
the Social Security Act precludes payment to  any provider of services unless

“there has been furnished such  information as may be necessary in
order to determine the amounts due
such provider” (42 U.S.C. section
13951 (e)). It is expected that the  patient's medical records will
reflect the need for the care provided.  The patient's medical records
include the physician's office
records,  hospital records, nursing
home records, home health agency records, records from  other
healthcare professionals and test reports. This documentation  must be
available upon request.”

Reference the following publications for
  documentation requirements for HCPCS code E0650 -
E0652, the DME
MAC A  Supplier Manual and the Pneumatic Compression Devices (L11503) LCD.
These are available on the DME MAC A Web site at: http://www.medicarenhic.com/dme/index.shtml

_____________________________________________________________________________
_____________________________________________________________________________
_____________
Document Name: DME Web site Article Template Document
  Number: TMP-EDO-0049
Release Date: 11/28/2007 Version: 1.0
The master
copy  of this document is stored in the NHIC ISO Documentation
Repository.
Any  other copy, either electronic or paper, is an uncontrolled
copy and must be  deleted or destroyed
when it has served its
  purpose.

------------------

NHIC, Corp., Medicare DME MAC
  Jurisdiction A has posted the results of a review of claims for a
lymphedema pump. The review revealed that over half of the claims for
  lymphedema pumps have been
rejected or down-graded. An analysis of
the  reasons for rejection can help future requests for these
devices. The  results point up the importance of having a well-written
Certificate of Medical  Necessity
(CMN) DME MAC Form 04.04B /CMS
Form 846  Pneumatic  Compression Devices signed by the
patient's
physician.

The CMN  must show that the use of a multichambered sequential
pressure pneumatic  compressor with
calibrated gradient pressure is
medically necessary for  the treatment of the patient's lymphedema, that
other "more  conservative" protocols such as elevation, compression and
exercise have been  tried and
have not been successful, that there
is a medical reason for  this patient to have a pump because of
difficulty in performing CDT at  home. Note that 14% of the claims were
denied on the basis that
"equipment is the same or similar to
equipment already in use" even though  Medicare frequently
requires
a failed trial of non-segmented pumps  before a more appropriate model is
approved [Ref.
LCD  L11503].

Physicians must be meticulous
and complete in writing their  prescription, including the diagnostic code
for lymphedema, the  physician's name address and NPI, and as full a
description of the type of pump
that is medically indicated,
including the designation of the kinds of  garments required (e.g. full sleeve
or
legging, upper or lower body  segment, etc.)

Bob
Weiss


Results of Widespread Prepayment  Review of Claims for HCPCS
Code E0652
(Pneumatic Compressor, Segmental Home  Model with Calibrated
Gradient Pressure)

Posted October 30,  2009

The DME MAC A Medical
Review Department concluded a widespread  review of HCPCS code
E0652
from June 2009 through September  2009.

The results of the quarterly
review of the claims from June 1, 2009  through September 30, 2009
identified eight hundred sixty-five (865)  claims of which two hundred
sixty-three (263) were denied.
This  resulted in an overall Charge
Denial Rate of 54.00%.

The following are  the top five (5) reasons for
denial:
o The equipment is considered not  reasonable and necessary (69
claims)
o The prescription is incomplete (46  claims)
o Duplicate claims
(43 claims)
o Equipment is same or similar to  equipment already in use (38
claims)
o Claim not payable under Jurisdiction A  (e.g., claim submitted to
incorrect contractor) (16 claims)

The other  reasons for denial are as
follows: (51 claims)
o Patient eligibility (e.g.,  patient cannot be
identified as Medicare insured; beneficiary not covered by
Medicare;
or beneficiary covered by another plan or HMO, etc.)
o Date of  death
precedes date of service
o Missing or incomplete supplier  information
o
Claim contains incomplete or invalid information (e.g., missing  or incomplete
diagnosis or condition)
o No response to medical records  request
o The
equipment was provided while the patient is in the nursing  home
o Lifetime
benefit maximum for equipment has been reached

The  Local Coverage
Determination (LCD) for Pneumatic Compression Devices (L11503)  states in
part:

Pneumatic Compression Devices are only covered  for the
treatment of lymphedema or for the
treatment of chronic venous
  insufficiency with venous stasis ulcers, prescribed by a physician and
determination by the physician of the medical necessity which must
include  the following:
o The patient's diagnosis and prognosis;
o
Symptoms and  objective findings, including measurements which establish the
severity of the
condition;
o The reason the device is required,
including the  treatments which have been tried and failed; and
o The
clinical response to  an initial treatment with the device. The clinical
response includes the change
in pre-treatment measurements, ability
to tolerate the treatment  session and parameters and ability of
the
patient (or caregivers) to  apply the device for continued use in the
home.

The medical documentation  submitted for five hundred thirty-four
(534) claims supported the medical
necessity for a lower level item,
thus the services were down-coded to the  least costly alternative.

The
Pneumatic Compression Devices (L11503) LCD  states:

“When a segmented
device with manual control of the pressure in  each chamber (E0652) is ordered

and provided, payment will be based on  the allowance for the least
costly medically appropriate
alternative,  E0651, unless there is
clear documentation of medical necessity in the  individual case. Full
payment
for code E0652 will be made only when  there is documentation that the
individual has unique
characteristics  that prevent satisfactory
pneumatic compression treatment using a non-segmented
device (E0650)
with a segmented appliance/sleeve (E0671 - E0673) or a  segmented device without

manual control of the pressure chamber  (E0651).”

For any
item to be covered by Medicare, it must:
o Be  eligible for a defined
Medicare benefit category;
o Be reasonable and  necessary for the diagnosis
or treatment of illness or injury or to improve the
functioning of a
malformed body member; and
o Meet all other  applicable Medicare statutory
and regulatory requirements.

Suppliers are  reminded that documentation
must be made available to the DME MAC upon  request.
Reference the following
under the Documentation Requirements section  in the Pneumatic Compression
Devices (L11503) LCD, which states in  part:

“Section 1833 (e) of
the Social Security Act precludes payment to  any provider of services unless

“there has been furnished such  information as may be necessary in
order to determine the amounts due
such provider” (42 U.S.C. section
13951 (e)). It is expected that the  patient's medical records will
reflect the need for the care provided.  The patient's medical records
include the physician's office
records,  hospital records, nursing
home records, home health agency records, records from  other
healthcare professionals and test reports. This documentation  must be
available upon request.”

Reference the following publications for
  documentation requirements for HCPCS code E0650 -
E0652, the DME
MAC A  Supplier Manual and the Pneumatic Compression Devices (L11503) LCD.
These are available on the DME MAC A Web site at: http://www.medicare nhic.com/  dme/index.
shtml

____________
_________ _________  _________ _________ _________ _________
_________ _________ _________  _________ _________ _________ _________
_________
_________ _________  _________ __
Document Name: DME
Web site Article Template Document Number:  TMP-EDO-0049
Release Date:
11/28/2007 Version: 1.0
The master copy of this  document is stored in the
NHIC ISO Documentation  Repository.

----

Worth
reading!

http://www.aarpmagazine.org/money/health_claim_game.html?print=yes#

If you need help with your
lymphedema  claim please contact me.

Bob Weiss
LymphActivist@aol.com


------


Thu, 12 Nov 2009
  13:49:00 -0600


Date: 11/12/2009
Subject: AHRQ Draft TA for
  review
Content: and Treatment of Secondary Lymphedema



The
  Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment
  Program will be
posting a draft technology assessment for review on
  November 18, 2009. This draft is entitled
"Diagnosis and Treatment
of  Secondary Lymphedema."  If you are interested in reviewing this
document, please visit: http://www.ahrq. gov/clinic/  ta/tareview.
htm
.
  The document will be available
for review from 9:00 AM on November
18,  2009 to 5:00 PM December 8, 2009.


Call for Public
  Review

--------------------------------------------------------------------------------

The
  Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment (TA)
  Program
develops systematic reviews, health technology assessments,
and  other reports at the request of the
Centers for Medicare &
Medicaid  Services (CMS) Coverage and Analysis Group. These reports are
funded by  an Interagency Agreement from CMS to AHRQ and used to inform
national coverage
policies, discussion at public Medicare Evidence
Development and  Coverage Advisory Committee
(MedCAC) meetings,
and/or for other policy  considerations.

To get complete public review,
the AHRQ TA Program will  post draft reports on the AHRQ TA Web
site. To meet the timelines for  Medicare coverage decisions mandated by
the Medicare Prescription
Drug,  Improvement, and Modernization Act
of 2003, draft technology assessment reports  will be
available for
public review for a limited time. A notice will  be sent out on the CMS Medicare
Coverage
and AHRQ Effective Health Care  E-mail distribution lists 1
week before the posting of draft reports.
Each report will be
available for public review on this Web site for a  total of 2
weeks.

AHRQ's TA Program supports and is committed to the  transparency
of its review process. Therefore,
starting March 18, 2009,  invited
peer review comments and public review comments will be publicly
posted on the TA Program Web site at http://www.ahrq. gov/clinic/
  techix.htm

within 3  months after
the associated final report is posted on this
Web site.  The report authors' responses to the comments
(the
"disposition of  comments") will be posted on the same Web page as the
associated  comments.

Review Steps
When a draft Technology Assessment
report is  available for review, you may review the draft report
by
completing the  associated review form and then selecting "Submit" on the
form.

Note:  Comments received after the review period will not be
  accepted.



Available Soon
Diagnosis and Treatment of Secondary
  Lymphedema. Available for review November 18 to
December 8,
  2009

Questions

Please contact ahrqtap@ahrq. hhs.gov
if you have any  questions.

This is an opportunity (maybe the last for
another 10 years)  to use your knowledge and experience to
help
shape Medicare lymphedema  coverage policy.




--

Robert
Weiss, MS
Lymphedema  Patient Advocate
National Lymphedema
Network

----

If you are  one of the millions of people who are
struggling to pay
medical bills, you  should be aware of the steps you can
take to reduce
or manage your debt. If  you owe money to a hospital or
medical
provider, do not ignore your bills. It  will be harder to straighten
out
billing mistakes or get financial assistance  if you wait. Making
timely
payments will also help you avoid further debt,  damage to your
credit
score, lawsuits, and “garnishment” (deductions from  your wages or
bank
account). But, if you cannot pay anything right now, you  may be able
to
get financial assistance, and you should see if your provider
  will
agree to wait before charging interest or sending your debt to
  a
collection agency.

This consumer guide covers steps for paying your
  medical bills,
understanding your rights, and other information you need to
  know if
you are struggling with medical debt. The guide also includes links
  to
other useful resources.

http://www.familiesusa.org/resources/resources-for-consumers/coping-with-medical-debt.html

Robert Weiss, M.S.
Lymphedema
  Treatment Advocate
National Lymphedema Network

----

CMS MEDCAC
  Meeting on Lymphedema (Impressions of LymphActivist)

On November 18 the
  CMS Medicare Evidence Development & Coverage Advisory Committee
(MEDCAC) conducted a full-day forum on the evidence basis of lymphedema
  measurement and
treatment at their quarterly meeting, the first
time in  their ten-year existence that this subject was
discussed.

The  NLN took a leading position in organizing
lymphedema medical experts from around  the country
to “focus on the
quality of evidence surrounding the  diagnosis and treatment of secondary
lymphedema”. Evidence was  submitted to the Lymphedema Panel regarding
evidence supporting
commonly used lymphedema diagnosis and treatment
protocols. NLN Medical  Advisory Committee
(MAC) members sat on the
panel, gave an invited  speech, and gave scheduled and unscheduled
testimony.

The open  meeting featured a presentation of the
Technology Assessment HHS/AHRQ  commissioned
from McMaster
University Evidence-based Practice Center,  Hamilton ONT Canada, followed by
assessments by Stanley Rockson, MD and  Jane Armer, PhD, RN, FAAN. This
was followed by
scheduled public  comments from 13 lymphedema
experts from lymphedema and venous organizations.
The NLN was well
represented at this meeting and provided valuable  inputs to CMS.

The
Expert Panel comprised 10 voting members chosen from  the eighty-eight permanent
MEDCAC
members plus a Patient Advocate, an  Industry Representative
and three guest panel members who
were  non-voting. The goal of the
meeting was to present the best evidence on the  measurement and
diagnostic and treatment methods for secondary  lymphedema, to question
and hear testimony of the
community of experts  and to vote on the
adequacy of the evidence to support use (coverage?) of each
method.

In the afternoon the Panel questioned the presenters and
  discussed the evidence, with the goal of
eventually voting on a
number  of issues concerning their confidence in the adequacy of the evidence to

support coverage of individual measurement and treatment modalities.
It was  the suggestion of one of
the NLN MAC Physicians that the
treatment of  multimodal, and that it made little sense to vote on
individual  modalities when the current treatment standard CDT is a
combination of  modalities. CDT
was added to the list to be voted
on. CDT plus  sequential pneumatic compression was also added
since
one of the  high-level trials considered it.

An open vote by the expert
panel  indicated that the final assessment would be that there is at least
intermediate confidence that CDT alone, CDT with adjuvant pneumatic
  compression, compression
bandages and compression garments, and
  pneumatic compression devices produce clinically
meaningful
improved  health outcomes for lymphedema patients. A vote on measurement methods
was
that no imaging technique had adequate evidence to identify and
stratify  severity of secondary
lymphedema, that only physical exam,
  patient-reported symptomatology, water displacement and
circumferential  measurement had adequate evidence to determine limb
volume, and that only  patient-
reported symptomatology had adequate
evidence to identify  sub-clinical lymphedema.

Another conclusion was
that there is little  confidence that our knowledge and measurement tools allow

us to  classify secondary lymphedema into stages of severity that
will be useful to  guide choice of
therapy or predict response to
therapy.

We fared  much better with respect to the question of whether
there was expert confidence  that
improvement in a number of
measures would be associated with  improvement of patients' health. Limb
circumference, limb volume,  symptom assessment, limb function,
activities of daily living, frequency of
skin breakdown, frequency
of skin infection, quality of life assessment and  social integration were all

felt to have medium to high confidence  based on existing
evidence.

The MEDCAC Lymphedema Panel will be  publishing their final
assessment, with all supporting
evidence and  comments submitted by
the public, on the CMS MEDCAC web site within 90 days. The
assessment will presumably be used by the CMS Coverage & Analysis
  Group in future discussions of
Medicare coverage of lymphedema
  diagnosis and treatment. There will be future opportunities for
public  and expert inputs into proposed Medicare coverage changes and we
must continue  to take
advantage of these
opportunities.

Since most of the  clinical trials which went into these
determinations were trials involving upper  limb
breast
cancer-related lymphedema, the last question asked whether  there was confidence
that the
diagnostic strategies and treatment  methods were
generalizable to Medicare beneficiaries with
secondary  lymphedema.
There was intermediate confidence that they were  generalizable.

A key
point to be made here is that this entire meeting  was focused on the evidence
resulting from
randomized clinical trials,  and had no way of
considering clinical evidence, anatomical and biological
knowledge,
observational evidence, expert clinician opinion,  consensus-based guidelines,
case studies,
non-randomized experiments,  etc. The “rules of
evidence” do not consider this vast body of
knowledge and experience
that form the basis of lymphedema treatment. This  evidence was brought in
by the meeting attendees.

So what's the  bottom line, you
ask?

I am greatly encouraged. Medicare has finally,  after ten years,
started the process of looking into the
coverage of  lymphedema
diagnosis and treatment. The process of defining coverage change is a  long,
fairly well defined process that has finally started. The process
  starts with recognition that there is a
problem with current
coverage,  the gathering of peer-reviewed evidence, the evaluation of that
evidence and judgment by an expert panel that the evidence is sufficient
to  support a change. The
process then progresses to discussions of
the  ways coverage might change. Medicare then implements
the
changed  coverage policies at a national level, and they are flowed down to the
local  regions. The
process involves writing National and Local
Coverage  determinations, revising the HCPCS Codes,
revising billing
procedures,  etc.-a long process.

By law, the public and the stakeholder
communities  must be involved in every step of the process. I
was
gratified to see  that the stakeholder community was not only involved in this
important step, but
was able to influence the conclusions to the
good.

There were  still large gaps in the knowledge because the right
questions were not asked and  the
contracted technology assessment
valued process over substance. The  community was given only three
weeks to respond to the request for  evidence, and did not have the
benefit of seeing where the gaps
were in  the Technology Assessment
before the meeting. The absence of some groups of  stakeholders
to
submit evidence on the efficacy of their products led  to gaps in the issues
voted on (e.g. dielectric
constant measurement of  skin fluid
content, ultrasound measurement of skin thickness, MRI
diagnostics,
low level laser treatment), and therefore a lack of  recommendation of what
might be
promising measurement or treatment  modalities to receive
Medicare coverage. I hope that these
information  gaps will be
filled in future public interactions with the CMS coverage
  organizations.

We're on our way on a 2-3year voyage. Let's continue our
  research and trials to show that there is no
hard line between
primary  and secondary lymphedema (see recent Rockson editorials), and the
diagnostic and treatment techniques are the same. Let's accelerate our
  research and trials on diagnosis
and treatment of non-extremity
  lymphedema (e.g. breast, torso, head and neck). Let's get more
evidence  of effectiveness or non-effectiveness of non-conventional
treatments such as
electrical/electrostatic/electromagnetic
modalities, vibration modalities,  laser/light therapies, and
acupuncture techniques. Let's push our  knowledge on hormonal and
inflammation interactions with
lymphedema and  treatment of
recurrent infection.

We've taken the first step. That's the  importance
of the MEDCAC meeting that took place November
18. And I  think it
went well.

Robert Weiss, MS
Lymphedema Patient  Advocate
National
Lymphedema Network

The opinions expressed above are  solely those of the
writer, and do not reflect the policies or opinions
of any
organization, government agency or  manufacturer.

-----

Date
01/19/2010


Subject CMS Updates  to Coverage Pages
Content Posted
information from November 18 MEDCAC meeting.  Also updated Bariatric Surgery
and Carotid Artery Stenting facility  lists.
Medicare Evidence
Development & Coverage Advisory Committee  (MEDCAC)
Meetings

11/18/2009 - Lymphedema
Posted transcript from
  meeting
http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=51

----------------

The
following  are two extremely informative articles appearing in the New York
Times Health  Section
concerning health insurance and hospital
bills. In particular  read the end of the first article with sound
advice on filing claims of  insurance denials -- much the same as I have
been advising. The numbers of
denials made routinely by insurers is
astounding!

Fighting Denied  Claims Requires Perseverance
http://www.nytimes.com/2010/02/06/health/06patient.html?emc=eta1

A Guide Through a Medical
  Wilderness
http://www.nytimes.com/2009/08/08/health/08patient.html?_r=1


Bob

Robert Weiss,
  M.S.
Lymphedema Patient
  Advocate

--------------------------

A6542 Gradient compression
  stocking, custom made
A6543 Gradient compression stocking,
  lymphedema

Changed HCPCS Codes
A6549 Gradient compression
  stocking/sleeve, not otherwise specified

I am not authorized to speak
for  Medicare or offer advice in coding or reimbursement, but the
following  is my interpretation of the impact of the above changes on
lymphedema treatment
reimbursement.

There is a HCPCS group of
Gradient Compression  Stockings (GCS) which are listed in the 2010
HCPCS Code Book with  A-codes, appropriate for Surgical Dressings.
Listing does not guarantee
coverage, and the majority of these items
are coded with notes that  indicate coverage restrictions or
exclusions based on their not meeting  the coverage requirements for
durable medical equipment, splints
and  braces and surgical
dressings. They are therefore denied coverage in the  treatment of lymphedema

in the absence of an open wound. A detailed  analysis of the members
of this group follows:

A6530, A6533-A6541  Gradient Compression Stockings
@ various styles and compression
These are not  covered because they do not
meet the rentability requirement of SSA §1861(n) for
"DME" as found
in Coverage Issue #60-9/National Coverage Determination  (NCD) Manual §280.1
DME List. They are excluded as "surgical dressings"  when not used to
treat burns per NCD §270.5.
They are also excluded by  the Medicare
Contractor Manual (MCM section 2133 as they do not meet
the rigidity
requirement for "splints and braces". They are therefore not  covered as
surgical dressings
[SSA §1861(s)(5)], durable medical  equipment
[SSA §1861(s)(6)] and orthotics [SSA §1861(s)(9)].
Nowhere  are they
excluded from coverage in their medical function in lymphedema  compression
therapy as prosthetic devices [SSA  §1861(s)(8).

A6531-A6532
Gradient Compression Stocking, Below Knee, 30-40  and 40-50 mmHg
These
knee-high stockings have been covered as secondary  surgical dressings in the
treatment of open
venous wounds since  1/1/2006, when they replaced
the L8110 and L8120 prosthetic device codes. 
Local Coverage
Determinations (LCDs) exclude their coverage as surgical  dressings in the
treatment of
lymphedema per MCM 2079/Benefit Policy  Manual §100
Surgical Dressings. But this coverage
criteria does not  apply to
prosthetic devices.

A6544 Gradient Compression Stocking, Garter
  Belt
These are not covered for the same reasons as above.

A6545
  Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 mmHg
Thee wraps
  (CircAid T-3M and BiaCare CompreFit Universal Models 1101-1115 BKT/R) have
been approved for coverage since 1/1/2009 and 10/30/2009 respectively,
but  only in the presence of
open venous wounds. They have the same
  restrictions as A6531 and A6532 above, and must be billed
with an
AW  Modifier, designating and open stasis wound. The 2010 pricing for this item
is  $89.45.

The pricing codes for the three covered items is for surgical
  dressings, which means that a fixed
reimbursement is established
  independent of the actual cost of the item. Medicare Suppliers must
accept this fixed amount and cannot balance-bill the
  Beneficiary.

A6542 Gradient Compression Stocking, Custom Made and A6543 
and Gradient Compression
Stocking Lymphedema
Neither of these
GCSs  were covered for the same reasons stated above for A6533-A6541. Prior to

the administrative code change on 1/1/2006 they were designated as
  prosthetic devices L8210 and
L8220 and were covered. The HCPCS code
has  been deleted and the products described included in
the A6549
Gradient  Compression Stocking/Sleeve, Not Otherwise Specified. This HCPCS code
is
still not covered in the treatment of lymphedema in the absence
of an open  wound. So nothing was lost
that we had before. The two
deleted codes  did not cover upper limb compression sleeves which were
only
listed  with non-reimbursable S-codes.

The A6549 code used to apply only
to  "gradient compression stockings, and the description has been
broadened  to include sleeves. The inclusion of both stockings and
sleeves in a "not  otherwise specified"
category implies that the
category is wide, and  the reimbursement will be based on the usual cost and
not a fixed  amount for all items in this code. HCPCS defers pricing of
these items to the  DME MAC.
If these items are eventually covered
by Medicare as  prosthetic devices, the reimbursement may be
based
on the price of the  custom item and not a fixed reimbursement for the
group.

We must wait for  changes in the coverage LCD and Article to
define the coverage criteria t be  used for
this code, i.e. whether
an open wound is required or whether  these items, still coded with a surgical

supply A-code, would be  covered as prosthetic devices when used in
the compression treatment of
lymphedema. CMS is aware of my
successful ALJ decisions supporting this  interpretation.

Bob
Weiss

------------

Although the  following letter deals with
covered items such as rental items and recurring  supplies, it
might
be prudent to follow the same procedures to support  the recurring purchases of
compression
bandage systems, compression  garments and devices, even
though they are not currently covered by
Medicare. Always get a
prescription for these items from a PECOS listed  physician and purchase them

from a Medicare-enrolled Supplier if you  hope to be reimbursed
through the Medicare appeal  system.

Bob

Robert Weiss,
M.S.
Lymphedema Patient  Advocate
National Lymphedema
  Network
===========================================================

March
  17, 2010

Durable Medical Equipment - Documentation of Continued Medical
  Necessity
Dear Physician,
To assure that correct payment is made for
items  and services that are provided to Medicare
beneficiaries, the
need for  detailed medical documentation is paramount. If your treatment plan
includes
durable medical equipment, prosthetics, orthotics, and
supplies (DMEPOS),  Medicare requires that
suppliers have access to
information from the  patient's medical record that addresses the coverage
criteria for the  items prescribed. Accessibility of pertinent medical
record information protects  both the
patient and the supplier in
the event of an audit.
For many  items, Medicare coverage requires that
continued use must be assessed and  documented by
the treating
physician. Rental items such as oxygen,  nebulizers, CPAP, wheelchairs, and
hospital beds
and recurring supplies  such as glucose test strips,
urological supplies, and ostomy supplies must be
periodically
justified in the medical record. Ongoing need for and use  of the item must be
documented
in your patient's record in order for  Medicare to
continue reimbursement for the equipment or supplies.
In  these
instances, you or your staff should regularly review the use of medical
  equipment and supplies
by your patients. This review should be no
  different than your review of the continued need for
medication or
  other treatments.
Recent audits conducted by the Comprehensive Error Rate
  Testing program have shown that patients'
medical records
frequently  lack sufficient information to justify the continued need for the
item(s)
ordered. This results in claim denials for the DMEPOS
supplier and  potential financial liability for your
patient. When a
claim is denied,  the DMEPOS supplier may be unable to continue to provide the
item
(s)  ordered. Clearly, this outcome may affect your care plan.
As the patient's  treating physician, it is
important that you
understand the applicable  Medicare coverage criteria related to the DMEPOS you

are prescribing  and adequately document the applicable policy
criteria for those items on an  ongoing
basis.
Medicare DMEPOS
Local Coverage Determinations (LCDs),  which include details on specific
coverage criteria, are available in  the Medicare Coverage Database or
on each DME MAC's Web  site.
Sincerely,

Paul J. Hughes,
M.D.
Medical Director, DME MAC,  Jurisdiction A

Adrian M. Oleck,
M.D.
Medical Director, DME MAC,  Jurisdiction B

Robert D. Hoover, Jr.,
MD, MPH, FACP
Medical Director,  DME MAC, Jurisdiction C

Richard W.
Whitten, MD, MBA
Medical Director,  DME MAC, Jurisdiction
D

----

The following announcement summarizes  a change to the
Medicare claims and appeals procedures that
shortens  the time after
a service is provided for filing the initial  claim:


Timely Filing
Requirements for Medicare Fee-For-Service  Claims

On March 23, 2010,
President Obama signed into law the Patient  Protection
and Affordable Care
Act (PPACA), which amended the time period for  filing
Medicare
fee-for-service (FFS) claims as one of many provisions aimed  at
curbing
fraud, waste, and abuse in the Medicare program. Under the new  law,
claims
for services furnished on or after January 1, 2010, must be  filed
within one
calendar year after the date of service. In addition,  Section
6404 mandates
that claims for services furnished before January 1,  2010,
must be filed no
later than December 31,
  2010.
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/844LP34117?opendocument
--

Robert
  Weiss, MS
Lymphedema Patient Advocate
National Lymphedema
  Network


LymphActivist@aol.com

------

The following
  letter sent to physicians writing prescriptions for DMEPOS items clearly states
  the
requirement for documentation of the medical need for the
items.  Unfortunately the consequence of a
physician's or supplier's
  non-compliance with these statutes falls on the patient, who must pay for the

medical items. It is always a good idea for you, the patient, to
obtain  a copy of your medical records
and obtain a letter of
medical necessity  for all compression items you
need.


Bob

Robert Weiss,  M.S.
Lymphedema Patient
Advocate
National Lymphedema
  Network
========================================================
Attention
  Physicians Ordering Supplies!

Dear Physician,
The National Durable
  Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Task
Force
would like to encourage physicians to please respond to any  Comprehensive Error
Rate Testing
( CERT ) documentation request they  receive from CERT
or the providing supplier.
DMEPOS suppliers can only  provide to the CERT
contractor the documentation that the physicians
provide to them. In
order for DMEPOS suppliers to continue to provide the  necessary items/service
to
your patient, they must be able to rely on  your cooperation in
providing any additional documentation
requested. S  ince physicians
are the ones treating the beneficiaries and are responsible for  maintaining
records to support medical necessity of the services they  provide, this
typically means copies of your
office notes, pertinent  test
reports, and other pertinent healthcare records maybe required to support
the DMEPOS items/service ordered. As it is stated in the Social
  Security Act:
Section 1833(e) of the Social Security Act precludes payment
to  any provider of services unless "there
has been furnished such
  information as may be necessary in order to determine the amounts due such
provider." It is expected that the patient’s medical records will
reflect  the need for the care provided.
The patient’s medical
records include  the physician’s office records, hospital records, nursing home

records,  home health agency records, records from other healthcare
professionals and test  reports.
This documentation must be
available upon request.
When  physicians are unable to provide the requested
documentation, the suppliers  receive denials for
the items billed
and their payment is recouped  which could result in your patient being
financially
responsible for  all or part of the charges for the
items/service received.
The DMEPOS Task  Force is asking for the cooperation
of the physician community. If a supplier
contacts your office to
request additional clinical documentation,  partner with the supplier to
establish
what clinical records are needed  to support that the
service/item you ordered is medically necessary.
Section  1842(p)(4) of the
Social Security Act mandates that:
[i]n case of an item or  service…ordered
by a physician or a practitioner…but furnished by another
entity,If
the Secretary (or fiscal agent of the Secretary) requires the  entity furnishing
the item or service
to provide diagnostic or other  medical
information in order for payment to be made to the entity, the
Physician or practitioner shall provide that information to the entity
at  the time that the item or service is
ordered by the physician or
  practitioner.
Providing medical records to the supplier is not a violation
of  the HIPAA Privacy Rule. Thank you for
your cooperation in future
  documentation requests.
The National DMEPOES Task
  Force

-------

April 14, 2010
Medicare Appeals – The Importance
  of Getting it to the Right Place at the Right Time!

Over the past year,
  the Qualified Independent Contractor (QIC) Part B North (the processor of
second – level appeals or reconsiderations) has consistently made a high
  rate of dismissal decisions.
Based on data analysis, the driving
factor  in this high rate is that appellants, primarily providers, request
reconsideration when a redetermination (first level appeal performed by
  CIGNA Government Services
following the processing of the original
  claim) has not been completed.

While often the cause appears to be
simply  confusion over the steps of the appeals process and the
parties  involved, we have also noted that some providers are confusing
written and  telephone inquiry
responses from CIGNA Government
Services with  official redetermination decisions. In accordance
with current  instructions, contractors are required to issue a written
notice of  redetermination. If you
disagree with this decision, you
may then file  a reconsideration request in writing with the QIC.

Please
  remember…..

Your first level appeal, a redetermination, is performed by
  the contractor who processed the original
claim and those requests
  should be sent directly to CIGNA Government Services. Sending a first level
appeal request to the QIC will result in a dismissal.

* You have
  120 days from the date of receipt of the Remittance Advice to request a
  redetermination.
You do not get extra days if you send it to the
wrong  entity (i.e. if you send it to the QIC and
subsequently
receive a  dismissal for no redetermination, the 120 day clock is still ticking
against the
original claim process date).

* The Medicare
Redetermination  Notice (MRN) should specifically reference the date of the
original
decision, state a clear decision of favorable, partially
favorable,  unfavorable or dismissed, and advise of
any further
appeal rights with  the QIC’s address. Please review the entire MRN
carefully.

* Your  request for a second level appeal, a reconsideration,
should be sent directly to  the QIC at the
address in the MRN,
within 180 days of receipt of the  notice. It is helpful if you include a copy
of the
redetermination  decision.

Lastly, please be sure your
request details specifically all  the claims you are requesting an appeal on,

including the beneficiary’s  name, the Medicare Health Insurance
claim number, the dates of service at
issue, the services at issue,
your reason for appealing, the name and  signature of the party or
representative of the party, and the name of  the contractor that made
the redetermination.



Bob

Robert  Weiss, M.S.
Lymphedema
Patient Advocate
National Lymphedema
  Network


-------------------------------

Extension of Therapy
  Cap Exceptions Process


Section 3103 of the Patient Protection and
  Affordable Care Act extends the
exceptions process for outpatient therapy
  caps.  Outpatient therapy service
providers may continue to submit claims
  with the KX modifier, when an exception
is appropriate, for services
  furnished on or after January 1, 2010, through
December 31, 2010.   


Therapy caps are determined on a calendar year basis, so all patients
  began a
new cap year on January 1, 2010.  For physical therapy and speech
  language
pathology services combined, the limit on incurred expenses is
  $1,860.  For
occupational therapy services, the limit is $1,860.  Deductible
  and coinsurance
amounts applied to therapy services count toward the amount
  accrued before a
cap is reached.


Bob

Robert Weiss,
  M.S.
Lymphedema Patient Advocate
National Lymphedema Network

Medicare Advantage premiums to dip
in  2011
    ..By Susan Heavey Susan Heavey – Tue Sep 21, 4:46 pm
  ET
WASHINGTON (Reuters) – Elderly and disabled Americans enrolled in private
  Medicare health insurance
plans will pay slightly lower premiums in
  2011 while gaining more benefits from recently passed healthcare
reforms, U.S. health officials said on Tuesday.

The plans, called
  Medicare Advantage, are offered by health insurance companies as an alternative
  to
traditional, government fee-for-service Medicare. Rates are
expected  to be 1 percent lower next year than
in 2010, the
government's Centers  for Medicare and Medicaid Services (CMS)
said.

Enrollment in the plans is  expected to grow 5 percent. More than
11 million people are already enrolled in
the plans, which have come
under fire from critics who say the  government pays too much to the companies

running them.

Jonathan  Blum, director of CMS' Center for
Medicare, said the lower costs and projected  expansion show
that
companies are still interested in offering such  plans despite new consumer
protections under the
healthcare law and  recent payment caps to
insurers.

"This is still a very attractive  marketplace for Medicare
Advantage plans," he told reporters.

Companies  such as Humana Inc and
UnitedHealth Group Inc are some of the biggest providers  of such
plans.

Shares of health insurers were up more than 1  percent on
both the Morgan Stanley Healthcare Payor Index
and the  S&P
Managed Health Care Index, outpacing the stock market  overall.

Stifel
Nicolaus analyst Thomas Carroll said the government's  announcement was "in line
with our view of
what the competitive  environment will be like next
year."

The companies, Carroll said, appear  poised to endure some margin
deterioration in order to boost market
share, just as the post-war
baby boomer population becomes eligible for  Medicare.

The news comes as
the healthcare reform law, passed in March,  hits its six-month anniversary this
week,
triggering a host of changes  for insurers overall, such as
ending lifetime coverage caps and banning policy
cancellations after
an enrollee gets sick.

Under the law,  Medicare Advantage consumers will
see their out-of-pocket expenses limited and a
reduction in how much
they have to share costs when it comes to kidney  dialysis, chemotherapy and
other
expensive care, Blum  said.

Starting in January,
enrollees can also see greater discounts for  prescription drugs sold either as
a separate
Part D plan or as part of  bundled Medicare Advantage
coverage.

The healthcare law offers a 50  percent discount from
drugmakers in the so-called 'donut hole' when drug
benefits
temporarily stop. Officials also said more insurers were expected  to offer
plans that covered the
gap.

Overall, about 5 percent of
  beneficiaries will have to choose a new provider because their Medicare
Advantage plan has shut down, officials said.

The insurance
industry  warned, however, that seniors can expect more costs and fewer benefits
with
Medicare Advantage plans after payment freezes have more time
to take  effect.

"As deep cuts go into effect in the coming years,
government  experts have forecasted that millions of
seniors will
experience higher  costs, reduced benefits and fewer choices," America's Health
Insurance Plans
President and CEO Karen Ignagni said in a
statement.

The group,  along with its insurer members, fought against
many of the healthcare reforms  before they
passed but now says it
is committed to implementing the  law.

The government's Centers for
Medicare and Medicaid Services said  some companies chose to abandon
the Medicare business next year, mostly  those offering private
fee-for-service plans that wanted to increase
beneficiaries' costs
while increasing profit margins.

About 300 out  of 2,100 plans were not
allowed to offer plans unless companies agreed to change  them,
officials said. Most agreed to make changes, but others did
  not.

(Reporting by Susan Heavey; Additional reporting Lewis Krauskopf;
  Editing by Dave Zimmerman, Gary
Hill)


The following
presents  a rare opportunity to get your suggestions considered regarding
changes to the
Medicare coverage and billing of physical and
occupational therapy  protocols for treatment of
lymphedema. You
have a chance to do more  than just complain about reimbursement for lymphedema

services you  provide.Are you happy with your reimbursement for: 
Patient instruction in home  self care; 
Time for measurement of
swelling, skin tone, bioimpedance,  etc.;    Time in bandaging;  Cost of
bandages
used incident to your  services (as distinguished from the
bandages provided as replacements for home  use)
[issue: billing
Part B VS DME];  Compression garment measurement,  fitting, specification,
evaluation?Do
you feel that there should be  special qualifications
for lymphedema providers?Should there be a separate
code for CDT and
MLD other than 97140 to distinguish these procedures from  other physical
therapy and
rehabilitation procedures?Should there be  coordination
between the services provided under 97140 and
97016?Do you  feel
that the goals of physical therapy and rehabilitation and the goals of
complexdecongestive
therapy should be distinguished from each other and  policies reflect that
distinction?
Meetings are scheduled in Mid October  where you can present
your comments and propose changes to
the Palmetto  Medical
Directors, and then there will be a 6-week comment period to submit  formal
comments.J1 Part B LCD DL28290 Comment Period Start October
  15

Share with your staff - The comment period for J1 Part B Local
  Coverage
Determination (LCD) Physical Medicine and Rehabilitation Policy
  DL28290
will begin on October 15 and end on December 3,
  2010.
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~89GQLZ0524?opendocument
OPEN
  DRAFT LCD MEETINGS OCTOBER 2010

Palmetto GBA J1 A/B Medicare
  Administrative Contractor (MAC) has scheduled Open Draft Local
Coverage  Determination (LCD) meetings in the following areas in October
2010. The general  public is
invited to submit information related
to the proposed LCDs  for Palmetto GBA's consideration. The draft
LCDs will be posted in the  next few weeks on our Web site.

LCDs
are administrative and educational  tools that assist providers, physicians and
suppliers in submitting
correct Medicare claims for
coverage.

California
Time: 9 a.m. to  11 a.m. PDT on October 19,
2010
Location: Crowne Plaza San Francisco  International Airport, 1177
Airport Blvd., Burlingame, CA  94010
Hawaii
Time: 8 a.m. to 10 a.m. HDT on
October 14, 2010
Location:  The Pacific Club, 1451 Queen Emma Street,
Honolulu, HI 96813
Nevada
Time:  9 a.m. to 11 a.m. PDT on October 21,
2010
Location: Nevada State Medical  Association, 2590 E. Russell Road, Las
Vegas, NV 89120


Robert Weiss,  M.S.
Lymphedema Treatment
Advocate
National Lymphedema  Network


A Message for North Carolina
Physical Therapy  Providers

This is to alert you that July 15, 2010, CMS
will be releasing  approximately 5,000 Comparative Billing
Reports
(CBRs) studying the  comparison of a provider’s utilization of the KX modifier
with their peers in
their state and across the nation. A single
state release will be done  first, followed by a national release.
North Carolina has been chosen  as the single state; approximately 70
CBRs will be disseminated initially,
with the remaining CBRs to
follow. The purpose of this CBR is to educate  independent Physical Therapy
providers and help prevent improper  payments.  A sample is attached.
Please note in the sample, that
providers who have questions about
the content of their CBR can call the  CBR Support Team at 530-896-
7080, 8 a.m. to 5 p.m. local time. They can  also get answers to their
frequently asked questions by visiting
the  CBR Services website at
www.cbrservices.com

Click
here for the sample  file
http://www.cignagov ernmentservices.  com/partb/ pubs/pdf/
A-CBR001. pdf

CBR
Services Overview

The  Centers for Medicare and Medicaid Services (CMS)
awarded the Comparative Billing  Report (CBR)
contract to SafeGuard
Services LLC (SGS). A Comparative  Billing Report or CBR is a documented
analysis that shows a provider's  billing pattern for various procedures
or services and compares that billing
to their peers.

CMS has
authorized SGS to begin producing nationwide  CBRs beginning in 2010. SGS, as
the CBR
Producer, has begun to develop  an inventory of potential
topics for study. CBRs will be produced using
national data from
Medicare A, B and DME. Once each study has been  completed, the CBR will be
mailed or faxed to the providers that were  selected under the topic
criteria.  A maximum of 5,000 providers
will  be selected per CBR
topic. The CBR, approximately 4 pages in length will also be  distributed to
each
provider in a PDF format. If, after reviewing the  document the
provider has any questions, they would then
be able to  call into
the SGS CBR support team, whose contact information will be provided  on each
CBR.

The CBR is not intended to be punitive or sent as an  indication of
fraud. Rather it is intented to be a
proactive statement  that will
help the provider identify potential errors in their billing practice.  A CBR

contains peer comparisons which can be used to provide helpful
  insights into their coding and billing
practices. The information
  provided is designed to help the provider prevent improper billing and
  payment.



August 19, 2010 -

Correct Coding for Pneumatic
  Compression Devices
Pneumatic compression devices (PCD) consist of an
  inflatable garment for the arm or leg and an electrical
pneumatic
pump  that fills the garment with compressed air. The garment is intermittently
  inflated and
deflated with cycle times and pressures that vary
between  devices. Several categories of these devices
exist. It is
important to  use the correct HCPCS code for the item provided.


PCDs
used for the  treatment of lymphedema and chronic venous insufficiency with
ulcers are coded  based
upon the characteristics of the base device.
The codes used  are:


•     E0650 - PNEUMATIC COMPRESSOR,
NON-SEGMENTAL HOME  MODEL
•     E0651 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME
MODEL WITHOUT
CALIBRATED GRADIENT PRESSURE
•     E0652 -
PNEUMATIC COMPRESSOR,  SEGMENTAL HOME MODEL WITH
CALIBRATED GRADIENT
PRESSURE

PCDs used  for the treatment of arterial disease are
coded:


•     E0675 - PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE,
RAPID
INFLATION/DEFLATION  CYCLE,FOR ARTERIAL INSUFFICIENCY
(UNILATERAL AND
BILATERAL  SYSTEM)

Sleeves used with E0650 -
E0652 and E0675 are billed separately  using codes E0655 - E0673 depending
upon the specific item  provided.


There are other types of
PCDs that are often referred to as  deep vein thrombosis (DVT) pumps, massage

therapy pumps, post surgical  DVT preventative pumps, etc. (not all
inclusive). These types of devices are
coded:


•     E0676
- INTERMITTENT LIMB COMPRESSION DEVICE  (INCLUDES ALL
ACCESSORIES),
NOT OTHERWISE SPECIFIED

The  garments/sleeves that are used with E0676
are included in the payment for E0676  and must not be
billed
separately. If a supplier chooses to bill  separately for the garment/sleeve,
then HCPCS code A9900
- MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR
SERVICE COMPONENT OF
ANOTHER HCPCS CODE must be
used.


HCPCS code A4600 - SLEEVE FOR  INTERMITTENT LIMB COMPRESSION
DEVICE,
REPLACEMENT ONLY, EACH is used  only when the sleeve is
being replaced, not at the time of initial
issue. This code may only
be used with compressors coded with E0676. HCPCS  codes E0655 - E0673
must
not be used when billing for garments used  with E0676 devices.


Refer
to the Local Coverage Determination (LCD)  and Policy Article for Pneumatic
Compression Devices
for coverage and  HCPCS coding
requirements.

August 23, 2010 -



Physical  Therapists Are
First Recipients Of CMS Comparative Billing  Reports



The Centers
for Medicare & Medicaid Services mailed  its first-ever comparative billing
reports (CBRs) to
as many as 5,000  physical therapists during the
week of Aug. 9, according to an Aug. 16 e-mail  notice
from
CMS.



The CBRs, produced by SafeGuard  Services LLC and
distributed by Livanta LLC under contracts with
CMS,  compare
providers' individual billing practices for specific procedures and  services
with their peer
group. CMS developed the program to reduce  improper
payments and to educate providers on Medicare
billing
  requirements.



CMS has issued similar reports in the past,
  including the Program for Evaluating Payment Patterns
Electronic
Report  (PEPPER) sent to inpatient hospitals, and Resource-Based Relative Value
Scale
(RBRVS) feedback reports sent to physicians, but this is the
first time  CMS has issued CBRs, agency
spokesman Peter Ashkenaz
told BNA Aug.  17.



The initial CBRs apply to outpatient physical
therapy  services provided by independent physical therapists
and
are based on  2009 Medicare claims data.



Physical therapists were
chosen due to  an identified vulnerability in their billing procedures centered
on use
of the KX modifier. The KX modifier is required to indicate
that a service  was medically necessary and
justified by medical
records, that the  physical therapy financial limitation cap was met, and that a
patient's
condition requires further
treatment.



Moving forward,  SafeGuard will produce and send new
CBRs to Livanta each month for distribution  to
providers.



By James Swann



Information  on
the CBR program is at
  http://www.safeguard-servicesllc.com/cbr/default.asp.



Medicare
  Provider-Centered Comparative Billing Report (CBR)



Last week,
the  Centers for Medicare & Medicaid Services mailed Comparative Billing
Reports  (CBRs) to
up to 5000 physical therapists across the
country.   The  reports provide comparative data on how an
individual health care  provider varies from other providers by looking
at utilization patterns.  We  have heard
from a number of providers
that this kind of information is  very helpful to them and have encouraged us to

produce more CBRs and  make them available to providers. 




These reports are not  available to anyone but the provider who
received them.  To ensure privacy, CMS
presents only summary billing
information. No patient or case-specific  data is included.  A sample is
provided in this communication. These  are tools to help providers
comply with Medicare billing rules and
improve the level of care
they furnish to their patients, our  beneficiaries.



Provider Help
Desk

CBR Support Team at  530-896-7080

CBR Services website at
www.cbrservices.com



September
2, 2010  -



The following policy article applies only to claims
made for  Medicare Part a or Part B services (not
DMEPOS) but has
some valuable  information for all Beneficiaries who have or are contemplating
sending
in claims because their provider or supplier says they are
not  covered.

MM6874- Beneficiary-Submitted Claims

This article,
based  on Change Request (CR) 6874, clarifies instructions for processing claims
by  carriers
and A/B MACs that are submitted by Medicare
beneficiaries. All  providers and suppliers are required to
enroll
in the Medicare program  in order to receive payment. In addition, Section 1848
(g)(4)(A) of the
Social Security Act requires all providers and
suppliers submit claims for  services rendered to Medicare
beneficiaries. The current manual  requirement instructs Medicare
contractors how to process claims
submitted by Medicare
beneficiaries when the provider or supplier refuses  to submit claims for
services
rendered and/or refuses to enroll in  Medicare. Read more
at http://www.cms.
gov/MLNMattersArticles/downloads/MM6874.pdf.

The  Amount in Controversy (AIC)
required to sustain Administrative Law Judge (ALJ)  and Federal
District Court appeal rights beginning January 1, 2010. o  The amount
remaining in controversy
requirement for ALJ hearing  requests made
before January 1, 2010, is $120. The amount remaining in
controversy
requirement for requests made on or after January 1, 2010, is  $130. o For
Federal District
Court review, the amount remaining in  controversy
goes from $1,220 for requests on or after January
1, 2009,  to
$1,260 for requests on or after January 1, 2010. That means that when you  file
a Medicare
appeal make sure that you combine all the items in a
  single appeal. You can combine claims so long as
they are all
within  the filing time window. And remember that the Amount In Appeal is the
cost of  the
material less your 20% co-pay, so if you want to
eventually be  considered by an ALJ your appeal must
be for an
aggragate amount of  greater than $163.00 Bob Robert Weiss, M.S. Lymphedema
Patient
Advocate  National Lymphedema
Network

-----------------------

May 20,  2010

Therapeutic
Shoes - In-Person Fitting and Delivery

Appendix C  of the DMEPOS Quality
Standards published in October 2008 addresses specific
requirements
for orthoses, prostheses, prosthetic devices, and therapeutic  shoes. Those
standards
include requirements for "an in-person  diagnosis-specific
functional clinical examination" by the supplier
to  determine the
need for a particular item as well as "face-to-face  fitting/delivery" by the
supplier.
Therefore, in order for therapeutic  shoes, inserts, and
shoe modifications to be covered, both of the
following criteria
must be met:

1.Prior to selecting the specific  items that will be
provided, the supplier must conduct and document an
in-person
evaluation of the patient; and,


2.At the time of  delivery of the
items selected, the supplier must conduct and document an  in-person
visit with the patient to ensure that the shoes/inserts/  modifications
are properly fit and meet the
beneficiary' s needs.
In  order to
meet these criteria, effective for claims with dates of service on or  after
July 1 , 2010, the
following documentation requirements must be
  met:

•The in-person evaluation prior to selecting the items must include
  at least an examination of the
patient's feet with a description of
the  abnormalities that will need to be accommodated by the
shoes/inserts/  modifications. For all shoes, it must include taking
measurements of the  patient's feet. For
custom molded shoes (A5501)
and inserts (A5513),  this visit must also include taking impressions,
making
casts, or  obtaining CAD-CAM images of the patient's feet that will be used in
creating  positive
models of the feet.


•The in-person
visit at the  time of delivery must include an assessment of the fit of the
shoes and inserts
with the patient wearing them.
Depending on the
items ordered, both  the evaluation and delivery could occur on the same day if
the
supplier  had both a sufficient array of sizes and types of
shoes/inserts and adequate  equipment on site
to provide the items
that meet the beneficiary' s  needs. Both components of the visit (criteria 1
and 2,
above) must be  clearly documented.

Documentation of
these visits must be available to  the DME MAC, PSC/ZPIC, RAC, or CERT
contractor
on request. If one or  more of these requirements are not met, the claim will be
denied as
statutorily noncovered.

This information will be
incorporated in a  future revision of the Therapeutic Shoes policy. Refer to the

Therapeutic Shoes Local Coverage Determination and Policy Article
for  additional information
regarding coverage, coding, and
  documentation.


From: NHIC DME MAC A
Robert Weiss,
MS
Lymphedema  Patient Advocate
National Lymphedema
  Network


__._,_.___

==========================

The
  revised Rehabilitation Therapy Information Resource for Medicare Fact Sheet
  (April 2010) is now
available in downloadable format from the
Centers  for Medicare & Medicaid Services? Medicare
Learning
Network at  http://www.cms. gov/MLNProducts/ downloads/ Rehab_Therapy_
Fact_Sheet.
pdf on the CMS website.  This fact sheet provides
guidance and resources  related to rehabilitation
therapy services,
coverage requirements, and  payment
systems.

-------------------

Change in the Amount in  Controversy
(AIC) Requirement for Administrative Law Judge Hearings and
Federal
District Court Appeals

MLN Matters® Number:  MM6894
Related Change
Request (CR) #: 6894
Related CR Release Date: May 7,  2010
Effective Date:
August 9, 2010
Related CR Transmittal #:  R1965CP
Implementation Date:
August 9, 2010

Provider Types  Affected
Physicians, providers and
suppliers submitting claims to Medicare  carriers, Durable Medical Equipment
Medicare Administrative Contractors  (DME MACs), Fiscal Intermediaries
(FIs), Part A/B MACs
(A/B MACs)  and/or Regional Home Health
Intermediaries (RHHIs) for services provided to  Medicare
beneficiaries are affected.

Provider Action  Needed
This
article is based on Change Request (CR) 6894, which notifies  Medicare
contractors of the
Amount in Controversy (AIC) required to  sustain
Administrative Law Judge (ALJ) and Federal District
Court  appeal
rights beginning January 1, 2010.

The amount remaining in  controversy
requirement for ALJ hearing requests made before January 1,
2010, is
$120. The amount remaining in controversy requirement for requests  made on or
after January
1, 2010, is $130.

For Federal District  Court
review, the amount remaining in controversy goes from $1,220 for requests
on or after January 1, 2009, to $1,260 for requests on or after January
  1, 2010

Please sure that your staff knows of these
  changes.

Background
The Medicare claims appeal process was amended by
  the Medicare, Medicaid and SCHIP Benefits
Improvement and
Protection  Act of 2000 (BIPA). CR 6894 modifies the Medicare Claims Processing

Manual, Chapter 29, Sections 220, 330.1 and 345.1 to update the AIC
  required for an ALJ hearing or
judicial court review. CR 6894 also
  expands the background information in the Amount in Controversy
General  Requirements, Principles for Determining Amount in Controversy
and Aggregation  of Claims
to meet Amount in Controversy sections
250, 250.1, 250.2 and  250.3 in the Claims Processing
Manual,
Chapter 29. The revised portions  of the manual are attached to CR
6894.

Additional Information
The  official instruction (CR 6894)
issued to your Medicare Carrier, A/B MAC, DME  MAC, FI and/or
RHHI
is available at www.cms.gov/Transmittals/downloads/R1965CP.pdf on the Centers for
Medicare & Medicaid Services (CMS) Web site.

A brochure
entitled, The Medicare  Appeals Process: Five Levels To Protect Providers,
Physicians
And Other  Suppliers provides an overview of the Medicare
Part A and Part B administrative  appeals
process available to
providers, physicians and other suppliers  who provide services and supplies to

Medicare beneficiaries, as well as  details on where to obtain more
information about this appeals
process.  The brochure is available
at www.cms.hhs.
gov/MLNProducts/downloads/MedicareAppealsProcess.pdf  on the CMS
Web site.

The
brochure is a very well done  information source.

Bob

Robert
Weiss, M.S.
Lymphedema Patient  Advocate
National Lymphedema
Network
--------------

The topic of  Medicare limits on therapy comes
up very often, and I wish to comment. My  comments
apply to current
Medicare policy, but to the extent that the  principles apply to lymphedema
medical
treatment in general, they may  be able to be used for
private insurance too.

Medicare has a policy this  year called the
"exception" rule which allows therapy beyond the annual
$1860 limit
when the additional treatments are deemed "medically necessary"  by the treating
physician.
The additional treatments might be necessary  because
there are other co-conditions which make the
therapy less
  efficient, force the therapy to be done slower than usual, extend to multiple
  body sites, etc.
This is all assuming that the therapist is
qualified  and competent, and is teaching the patient to do home
self-treatment  between clinical sessions.

Some of these
co-conditions might be  congestive heart failure, venous insufficiency,
peripheral arterial
disease, obesity, lipodema, multiple limbs or
body sites, diabetes,  etc.

If Medicare turns you down ask your physician
to write a letter of  medical necessity for additional
treatments
because these  co-morbidities make the treatment less efficient and therefore
require therapy
exceeding the statutory (policy for insurance)
limits.

Medicare  will reimburse ANY physical therapist or occupational
therapist why treats a  lymphedema
patient regardless of whether
that therapist has the  specialized lymphedema training. This occasionally
results in treatment  that may not be effective, and the patient reaches
the annual limits without
experiencing the improvement that would be
expected from a properly  qualified therapist.

ALWAYS check whether the
lymphedema therapist has  had adequate training and experience, and if
not,
find one who has. The  LANA national certification for lymphedema therapists
requires a minimum
of 135 hours of lymphedema training on top of a
current license in physical  or occupational therapy plus
one year
of clinical experience overseen  by a qualified lymphedema
therapist.

Bob

Robert Weiss,  M.S.
Lymphedema Patient
Advocate
National Lymphedema




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