oandp.com

After several redetermination letters were sent in for appeal to the
findings of the RAC auditors. I received Medicare appeal decision letters
stating that "because the submitted documentation did not support the
medical necessity of the service at issue", which was exclusively prosthetic
feet codes, ".it was determined that each procedure code was paid in error
on Claim Numbers.". Which now means that for the 11 active audits since
2/2012 that started with audits for feet codes only, 5 are now being
rejected as overpayment for the entire prosthesis. Only 5 because I haven't
got the letters on the others yet.



Every reason for denial is a result of improper/incomplete physician
documentation.



Has anyone on the list made it to the ALJ and succeeded? Is it just due
process to go through the appeals to get to the ALJ? I am on the
reconsideration phase for several claims but now will be back to the
redetermination phase for the audits on the entire prostheses.



Trevor Townsend, CPO

VIPO

Bakersfield, CA