ESCRIPTION OF THE ISSUE
All the ultrasound charges were denied by Medicare stating “These are non-covered services because this is not deemed a “medical necessity' by the payer”.
CONCEPT
Medicare Part B pays depends on the setting in which the testing is provided. If the ultrasound testing is performed in a doctor's office, freestanding clinic, or independent testing facility, Medicare Part B pays 80 percent of the Medicare-approved amount. If the testing is conducted in a hospital outpatient department, Medicare Part B pays the full Medicare-approved amount, except for a set co-payment that the patient is responsible for...
Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
1. The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper
2. The care must be performed or delivered by a healthcare provider who participates in Medicare.
REASON
We tried refiling these claims with higher specificity ICDs. For which only very few claims were paid by Medicare. And the rest were denied again as “These are non-covered services because this is not deemed a `medical necessity' by the payer”. We also tried appealing these claims towards MCR but was not successful. Hence we raised request to the Client for approval of adjustments. There is no response from the Client yet.
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