Medicare Appeals # 11525
This official government booklet has important information about:
■ How to file an appeal if you have Original Medicare
■ How to file an appeal if you have a Medicare Advantage Plan or other Medicare health plan
■ How to file an appeal if you have Medicare prescription drug coverage
■ Where to get help with your questions
Filing an appeal with Medicare
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Medicare Appeals Publication # 11525 60 pages
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HICAP CA * Rest of USA * (Health Insurance Counseling and Advocacy Program) provides free, confidential one-on-one counseling, education, and assistance to individuals and their families on Medicare, Long-Term Care insurance, other health insurance related issues, and planning ahead for Long-Term Care needs. HICAP also provides legal assistance or legal referrals in dealing with Medicare or Long-Term Care insurance related issues.
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***Sure they might be of help, but how much training, licensing, malpractice coverage and experience do licensed agents have. Look at all the information on this site!
Rights & Protections for
Everyone with Medicare
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Medicare Advantage Plan or Other Medicare Health Plan
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The Medicare Beneficiary Ombudsman
- This is NOT sales literature, but is provided as a public service for educational purposes.
- AARP Procedures on problems, complaints & appeals from EOC
See our general section on Appeals & Grievances
Question FAQs / Ask Us a Question
With all your experience, is there any effective [grievance] agency for me to go to with the HMO Medicare advantage plan [UHC – AARP] I have? One of UCLA, Endocrinologists made a huge medication error, from which I am very ill. UCLA has denied me a second opinion or a higher level of care.
Answer
***One of the very best places to view your rights and procedures for claim problems, appeals, grievances is in the full EOC – Evidence of Coverage that you have a right to view before purchasing or when you get it in the enrollment paperwork or shortly thereafter. Get your EOC go to Table of Contents – Then look for Appeals, claims procedures, etc. and of course the explanation of benefits and if your issue is actually covered.
Click here to read more of Patty’s situation, she has certainly been there, done that and got the T Shirt.
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Medicare and You 2020 #10050
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Since my orthopedic surgeon has indicated that I need Total Knee Replacement, how can I over-ride the Medicare requirement that I have Cortisone Injections before I can have the surgery?
All my extensive research shows that Cortisone is very damaging to skin, bones and surrounding tissue, just prolongs the damage to my knee, and means that I will be that much older perhaps necessitating a longer recovery.
I am also an athlete and I am unable to participate in my numerous sports so waiting for Total Knee Replacement means it will be much harder to re-gain my fitness.
Cortisone Injections are just another cost for Medicare (and me) when TKR will be the end result!
See our page on medical necessity.
What extensive research do you have that Cortisone isn’t the thing to try first?
Where do you find that Medicare requires cortisone first?
Check this instructional bulletin for your doctor
DOCUMENT MEDICAL NECESSITY TO AVOID DENIAL OF CLAIMS
CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments. To avoid denial of claims for major joint replacement surgery, the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings. Both physicians and hospitals are responsible for ensuring a complete and accurate record.
Unnecessary health care (overutilization, overuse, or overtreatment) is health care provided with a higher volume or cost than is appropriate.[1] In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending ($750 billion out of $2.6 trillion) in 2012.[2]
Factors that drive overuse include paying health professionals more to do more (fee-for-service), defensive medicine to protect against litigiousness, and insulation from price sensitivity in instances where the consumer is not the payer—the patient receives goods and services but insurance pays for them (whether public insurance, private, or both).[3] Such factors leave many actors in the system (doctors, patients, pharmaceutical companies, device manufacturers) with inadequate incentive to restrain health care prices or overuse.[1][4] This drives payers, such as national health insurance systems or the U.S. Centers for Medicare and Medicaid Services, to focus on medical necessity as a condition for payment. However, the threshold between necessity and lack thereof can often be subjective.
Overtreatment, in the strict sense, may refer to unnecessary medical interventions, including treatment of a self-limited condition (overdiagnosis) or to extensive treatment for a condition that requires only limited treatment.
It is economically linked with overmedicalization. https://en.wikipedia.org/wiki/Unnecessary_health_care
https://www.medicare.gov/hospitalcompare/Data/Surgical-Complications-Hip-Knee.html
I do not understand why you sent me this link…
So that you know what the other side of the issue, question is. How will you argue, if you don’t know the opponents position and where they are coming from? See page 8 of a Patient’s Guide to Navigating the Appeals Process – Identify.
Things to submit with your appeal
n A letter of support from your treating provider indicating the medical reasons that the requested service should be approved
n Notes from your treating physician that provide information on the medical care provided to you including how you responded to treatment
n The results of any relevant tests or procedures related to the requested service
n Any current medical literature or studies documenting the medical effectiveness of the requested services for experimental or investigational treatments
n Peer reviewed articles from your doctor’s professional journals or magazines that support the treatment being recommended
n Your own personal narrative or the narrative of an authorized representative describing the need for the requested service
This looks like the clinical bulletin for Medicare
The most common reason for total knee replacement surgery is arthritis of the knee joint. Types of arthritis include
osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). This arthritis
causes a severe limitation in the activities of daily living, including difficulty with walking, squatting, and climbing
stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for
a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of
pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement
with other conservative therapies such as steroid injections and physical therapy. Osteonecrosis and malignancy are
additional reasons to proceed with total knee replacement surgery. The goal of total knee replacement surgery is to
relieve pain and improve or increase patient function.
Total knee replacement surgery will be considered medically necessary when one or more of the following criteria are met:
Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following:
anti inflammatory medications,
analgesics,
flexibility and muscle strengthening exercises,
supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care],
activity restrictions as is reasonable,
assistive device use,
weight reduction as appropriate, therapeutic injections into the knee as appropriate.
Documentation Requirements
The medical record must contain documentation that fully supports the medical necessity and justification of the
procedure performed.
https://www.cgsmedicare.com/parta/pubs/news/2015/0415/cope29098a.html
Here are just 5 of MANY recent reports from the medical community showing that Cortisone DOES NOT FIX MY KNEE–it only masks pain and may cause damage!
*Harvard Medical School, Cortisone Report, Apr. 1, 2019
*WebMD, “Disadvantages of Cortisone Injections.”
*”Cortisone Injection Risks and Side Effects,” Emmanuel Konstantakos, MD Peer Reviewed, 2016, Arthritis Health
*Dr. McAlindon. “We now know that these injections bring no long-term benefit, and may, in fact, do more harm than good by accelerating damage to the cartilage.”
This study was supported by the NIH’s NIAMS (R01-AR051361) and National Center for Advancing Translational Sciences
*Repeated corticosteroid injections to the joint may speed cartilage degeneration.
Credit Timothy E. McAlindon, M.D., M.P.H., of Tufts Medical Center, Boston.
Please send the actual links… We are not getting compensated to help you. Please don’t make us spend an hour to find these papers. I did not see ANY requirement in the clinical bulletin or the Major Joint Replacement booklet requiring cortisone.
What complications might there be from knee replacement?
Cortisone was just the first recommendation by my physician. But I see from the Medicare Documents that it CAN BE ONE OF MANY. I’ve had several other treatments and none have worked of course, you can’t replace bone or cartilage once it’s gone. So I will argue that those suggested by Medicare have not worked and my doc agrees, and we’ll go from there.
https://www.kantorlaw.net/practice-areas/health-insurance-claims/
See our other page on appeals
I don’t have a grievance yet–so will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!
We need to use the exact proper terms.
Grievance—A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.
Appeal—An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
■ Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
■ Your request for payment for a health care service, supply, item, or prescription drug you already got
■ Your request to change the amount you must pay for a health care service, supply, item or prescription drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.
https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf
Will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!
Please when using technical terms, define them and provide a URL.
https://cgsmedicare.com/parta/pubs/news/2015/0215/cope28418.html
CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to conservative treatments.
Pre-surgical physical therapy progress notes are important in demonstrating how the patient has progressively worsened over a period of time. Noting that the patient has “failed conservative therapies” in the history and physical is a conclusive statement and should be supported by other specific, objective information in the patient’s medical record.
*****
https://cgsmedicare.com/parta/mr/pdf/total_knee_fact_sheet.pdf
One or more of the below conservative treatments have been tried and failed for 3 months or
more except in special circumstances where delay of definitive care is not appropriate:
• Anti-inflammatory medication:
Duration of treatment
• Analgesic
• Home exercise: Duration of treatment
• Physical therapy: Duration of treatment
• Use of cane or walker: Duration of treatment
• Weight loss: Duration of treatment
• Brace: Duration of treatment
• Cortisone shot(s): Duration of treatment
• Visco-supplementation: Duration of treatment
*****
https://www.mass.gov/files/documents/2018/05/30/mng-knee-arthroplasty.pdf
A summary of the non-operative, conservative treatment(s) that have been tried and have been unsuccessful in managing the patient’s condition;
*****
• A listing, description and outcomes of failed non-surgical treatments, such as:
– Trial of medications (for example, Nonsteroidal anti-inflammatory drugs (NSAIDs)).
– Weight loss.
– Physical therapy.
– Intra-articular injections.
– Braces, orthotics or assistive devices.
– Physical Therapy and/or home exercise plans.
– Assistive devices (for example, cane, walker, braces (specify type of brace), and orthotics) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf
The average hospital charge for a total knee replacement (TKR) in the United States is $49,500 to $57,000 https://www.healthline.com/health/total-knee-replacement-surgery/understanding-costs#9
Check out this Q & A for additional resouces to help with Medicare and Social Security Problems https://medicare.healthreformquotes.com/sign-medicare/general-enrollment-period/#comment-24943