Medical Review - JF Part B

Q1: Why are some HCPCS J0178 claims getting denied due to frequency?
A1: HCPCS J0178 (Eylea) is an injection of aflibercept. This drug typically is used to treat macular degeneration. Aflibercept is a recombinant protein produced in Chinese hamster cells. The fused protein consists of portions of human vascular endothelial growth factor-A (VEGF) and placental growth factor (P1GF) receptors fused to human IgG1. VEGF and P1GF act on receptor sites to stimulate neovascularization and vascular permeability. Aflibercept is indicated as a treatment for neovascular (or wet) age-related macular degeneration (AMD). The recommended dose for aflibercept is 2 mg every four weeks for the first 12 weeks followed by 2 mg once every eight weeks. The drug is for intravitreal administration only. We originally were denying HCPCS J0178 claims due to frequency because it was not being given exactly how the FDA label reads. After discussion with our Contracted Medical Directors (CMDs), they reviewed some peer reviewed literature and came to a conclusion. A decision was made that if providers are extending the intervals of Eylea (J0178), the documentation needs to support that the treatment is medically necessary and effective for the patient for us to allow the claims.

Q2: Why are my therapy claims for procedure code 97164 denied?
A2: Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations. Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care. A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Reevaluation requires the same professional skills as evaluation. The minutes for re-evaluation are documented in the same manner as the minutes for evaluation.

Refer to: Medicare Benefit Policy Manual (cms.gov) and Article - Billing and Coding: Re-Evaluation

Q3: I have sent in documentation on multiple claims/ADR letters and would like to know if you have received the documentation?
A3: You can check your submission via the Noridian Medicare Portal if they were submitted that way. The way in which claim documentation is received will have an impact on the timing of when/how documentation is received. Paper submissions via fax and postal mail are dependent on the mail room/processing queue volume/capacity of documentation received. Therefore, there is no actual time frame until the documentation is attached to a specific claim. For more information regarding how to submit medical records, please refer to the link below:

Refer to: Noridian Medicare Portal and How to Respond to an ADR

Q4: My spinal cord stimulator claims that Noridian asked for documentation are being denied. Why would this be happening?
A4: There is a Local Coverage Determination (LCD) for the spinal cord stimulators. Make sure that the criteria from the LCD is in the documentation. Often the psychiatric evaluation is missing.

Refer to: LCD - Spinal Cord Stimulators for Chronic Pain (L36204)