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TexasLadyBug

Medicare denial of gastro ordered tests

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I was confirmed as celiac in 2012 via blood tests and a EGD showing stomach damage.  I just did a follow up  procto but gastro didn't want to do another EGD.  He did order 2 tests Folic Acid Level (82746-GA) and cynocobalamin (Vitatmin B-12) level (82607-GA).  These tests were to check to make sure by body was getting vitamin absorption because of the celiac damage.

Medicare DENIED these 2 tests citing LCD (Local Coverage Determination) & Policy L34914.  This policy states:  "...Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter annual testing may be appropriate depending upon the indication and other mitigating factors."

Of course, one cannot determine "deficiency" until one tests for it.  Further I would think a celiac DX would be a "mitigating factor" since it causes malabsorption issues.   Has anyone every appealed this denial?  These tests cost me over $230. I'm thinking of appealing this denial but am seeking info from anyone who may have already done so and what result you got.

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You have been gluten free for 5 years - you should be able to absorb your vitamins.  I think it would make more sense to test if you are compliant with your diet and our antibodies have gone down.  

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You could call your doctors office and tell them what happened. Sometimes the doctor's office can contact the insurance company to let them know the test was medically needed. In some cases it is also a possibility that the wrong codes were put in for the reason for testing. In both instances the bill can be resubmitted. 

If the tests were done at your local hospital you could also call them and explain what is going on and depending on your income you may be able to get the costs reduced on a sliding fee scale.

I agree with Karen that a panel should be run to make sure that gluten isn't sneaking in somewhere. This is especially important if you are having any type of health problems.

 

 

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Yes, I would appeal.

I am trying to gauge how often those on Medicaid (and Medicare for that matter) are ordered Celiac tests, because my fear is, it's not often at all. I started a separate thread on the topic, but so far, no replies. I wonder if it's even covered. At any rate, I think it would be a great idea to get some kind of campaign started for better coverage.

Plumbago

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We appealed. First appeal was denied since "no diagnosis" was stated. What we told Medicare was since they had all the claims, they had all the DX and info so just look it up.  Wrong!  The appeal goes to a Medicare contractor who doesn't give a flip about you--you have to "spoon feed" them all the info that Medicare ALREADY HAS so they can process.  We were referred to a 2nd appeal status.  I did some internet research and found the document they mentioned as the basis of the denial.  In one paragraph of that guidance document it specifically states that CELIAC DX makes these blood test reimburseable.

So at this 2nd stage of appeal I sent a copy of this document underlining the paragraphs relating to celiac and a copy of my Doc's DX of celiac.  Just got notice that we WON!  Medicare will pay for the following procedures with a celiac diagnosis:

82746: Blood Folic Acid Serum

82607: Vitamin B-12

Your lab may tell you these tests are NOT COVERED by Medicare and make you pay up front.  They may cite Local Coverage Determination (LCD) #L34914 (do a search for that document)  Under the caption "Group 3 Codes" of L34914 it stated that ICD-10 code K90.0 Celiac Disease is a COVERED DX for CPT codes 82607 and 82746.

Don't accept a denial -- appeal it but document as I stated above.

 

 

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I am so glad you appealed! Persistence pays off! Yay you!

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That's really great that you appealed. My aunt has too enrolled herself under Medigap Plan G through a Medicare-approved company (https://www.thehealthexchangeagency.com/about-us/). This plan includes all the Part A and Part B coinsurance and co-pays, along with both parts deductibles and maximum hospital coverages including some tests too. Hope so that she does not have to face denial but in case, in future, she faces the denial, for sure I would suggest her to appeal for the same.

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