Doctor required blood tests for knee replacement not covered by Medicare! (medical, surgery)

[Dennis11003]

I had a total right knee replacement on March 12. Prior to this, my doctor required specific blood tests before surgery.

Yesterday, I received a notice from Quest (lab) that over $350 of these blood tests were not covered by Medicare and I would need to pay! I have Medigap F but since Medicare did not cover, they won't!

Is there anything I can do? Anyone else ever have this issue?

Thanks in advance.

Dennis

[Ariadne22]

Originally Posted by Dennis11003

I had a total right knee replacement on March 12. Prior to this, my doctor required specific blood tests before surgery.

Yesterday, I received a notice from Quest (lab) that over $350 of these blood tests were not covered by Medicare and I would need to pay! I have Medigap F but since Medicare did not cover, they won't!

Is there anything I can do? Anyone else ever have this issue?

Did the denial give a reason?

Of late, it seems any omission on "medically necessary" is being used in denial of what is clearly a medically necessary service.

It is quite possible coding and/or supporting data sent to Medicare by the lab did not include "medically necessary." If that is the case, ask docs office and/or lab to resubmit its request to lab for this "medically necessary" procedure and have lab resubmit to Medicare stating "medically necessary."

This happened to me a few months ago for what was clearly a "medically necessary" procedure. I would have developed sepsis without medical intervention. I haven't disputed the denial, yet, because provider isn't dunning me for payment - and I absolutely HATE fighting this kind of stupidity. But, I need to get on this before too much time goes by.

My determination said:

"non-covered services because this is not deemed a 'medical necessity' by the payer. This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd."

[Dennis11003]

Thanks. I'll start with the doctor and see what happens.

[Mawoods]

My husband has had 2 knee replacements with the required blood tests each time. All covered by Medicare. I wonder if an incorrect code was entered.

[rothbear]

There seems to be a lot of that going on in Medicare lately. I have been having this problem with an abdominal reconstructive surgery I had last October for 2 large hernias after being referred to a surgical group specializing in this due to the extensive work needed. I had a GI surgeon do the opening and rearranging of everything, then a plastic surgeon put in the mesh, removed excess tissue and sewed it all back up nicely. Now Medicare is saying they won't pay for the second surgeon because it wasn't medically necessary. Wait, what???? The GI person doesn't do the mesh and fix up, and the plastics doesn't to the "moving around". The office said they took care of all the needed approvals for it and since they do this kind of thing all the time they should know what they are doing. Apparently they have also put in for an appeal twice with the same results. I have never had this problem with my other surgeries.

Check your EOB to see if it says you won't be responsible for the charge. That is what my EOB is saying, although I feel bad that they aren't paying for it after doing an approval.

[Ariadne22]

Originally Posted by rothbear

Check your EOB to see if it says you won't be responsible for the charge. That is what my EOB is saying, although I feel bad that they aren't paying for it after doing an approval.

Thanks, rothbear. Just looked at my paperwork again. Yes, that is exactly what mine says. I'm not responsible. So, I guess I'll stop worrying about it. If Medicare won't pay because claim does not say "medically necessary" that is on the provider for sloppy billing. My provider hasn't bothered to resubmit the claim, either, even though they received the denial two months ago. Big health consortium - you would think they would care.

I, too, feel bad because I was very happy with the service and the experience at the urgent care facility. They deserve their money, albeit the Medicare reimbursement is 25% of what they billed.

[localinsight]

Two blood tests of mine were denied last year. I have Medicare & Suppl. F. I called the doctor and haven't heard anymore about it. It has been about 7 months. Sometimes the doctor has to submit more codes to get things covered. I always start there.