Medicare Resisting to Cover Gammagard IV
- Thread starter vertex
- Start date
I have no experience with this particular one, but maybe it's because it "could" be taken at home like insulin. I don't think that's an alternative for every patient, but it is an alternative method of administration. Still doesn't make sense that they would flat turn it down.
- 6,481
https://www.unitedhealthcareonline....edical Policies/Drug Policies/IVIG_policy.pdf
Page 11 of that document gives some situations where it is not considered medically necessary. Was there any pre approval work done prior to the start of the treatments?
I also see UHC has provided a long list of codes in the document. That might enable you to see if there is a coding issue in the submissions.
(edit was studying this out while somarco posted.)
- Thread starter
- #5
Thank you for that document. Very useful information.
The doctors office tried to infer to the policy holder that medicare had flat out denied coverage for the infusion.
I called the specialty pharmacy that the doctors office had been working through with the policy holder on the phone to try to get more information. As it turns out the specialty pharmacy is very familiar with medicare part B billing and diagnosis guidelines and has been waiting for the doctors office to supply the proper documentation which they had not done to insure reimbursement.
I think the doctors office just wanted the policy holder to accept that and move on.
The doctors office tried to infer to the policy holder that medicare had flat out denied coverage for the infusion.
I called the specialty pharmacy that the doctors office had been working through with the policy holder on the phone to try to get more information. As it turns out the specialty pharmacy is very familiar with medicare part B billing and diagnosis guidelines and has been waiting for the doctors office to supply the proper documentation which they had not done to insure reimbursement.
I think the doctors office just wanted the policy holder to accept that and move on.
- 6,481
http://www.igliving.com/magazine/articles/IGL_2013-02_AR-Transitioning-IG-Coverage-to-Medicare.pdf
I am not good at rapidly absorbing highly technical material so please forgive me if I waste your time with this. I found this document too when I was looking but did not post it because of its 2013 date and wasnt sure it would still be relevant. Your comment made me think of it.
Look at the last full paragraph in the lower rt corner of page 25. Maybe there is a cost issue going on with the doctor.
I am not good at rapidly absorbing highly technical material so please forgive me if I waste your time with this. I found this document too when I was looking but did not post it because of its 2013 date and wasnt sure it would still be relevant. Your comment made me think of it.
Look at the last full paragraph in the lower rt corner of page 25. Maybe there is a cost issue going on with the doctor.
Part B coverage for drugs can be a challenge outside of chemo. The doctor must be willing to incur the expense associated with the procedure AND be willing/able to code properly.
The other puzzle piece is finding a pharmacy that knows how to submit B Rx claims and is willing to do so.
Even when a doc is not directly involved, such as when insulin for a pump is involved, it may be difficult to find a pharmacy to supply insulin under Part B.
The other puzzle piece is finding a pharmacy that knows how to submit B Rx claims and is willing to do so.
Even when a doc is not directly involved, such as when insulin for a pump is involved, it may be difficult to find a pharmacy to supply insulin under Part B.
Similar threads
