Complete Story
 

08/26/2010

Lucentis – Medicare Coverage Update

By, Joy Newby, LPN, CPC, PCS, Newby Consulting, Inc.

In the last several weeks the OOS has received a number of inquiries regarding Medicare’s coverage of Lucentis. Several changes have occurred that are important for your office to know.

At the end of July, with an effective August 1, 2010  Palmetto GBA’s (Ohio Medicare) posted a Local Coverage Decision (LCD) for Chemotherapy & Biologicals LCD # L24394 (which includes Lucentis) included the following diagnoses that should support medical necessity of HCPCS code J2778 Ranibizumab; Lucentis

362.35            central retinal vein occlusion

362.52            exudative senile macular degeneration of retina

The full LCD is listed below:

Following the publication of the August “Medicare Advisory” notifying ophthalmologists that 362.35 had been added, the OOS contacted Palmetto GBA requesting additional ICD-9 codes be added. The Food and Drug Administration (FDA) approved Lucentis for treatment of “macular edema following retinal vein occlusion (RVO).” Two additional diagnosis codes may be used to describe this condition.

Palmetto advised the OOS that effective with dates of service on or after September 1, 2010, the Lucentis LCD would be updated to include two additional diagnosis codes.

362.36            venous tributary (branch) occlusion

362.83            retinal edema

The addition of these two new codes was made official by Palmetto in the September “Medicare Advisory”. See link to the advisory below.

http://www.palmettogba.com/Palmetto/Providers.nsf/files/September_2010_Medicare_Advisory-OHWV.pdf/$FIle/September_2010_Medicare_Advisory-OHWV.pdf

As the FDA’s approval for treatment of macular edema following retinal vein occlusion (RVO) was effective June 22, 2010. It is possible, that if billed before the effective dates posted by Palmetto, ophthalmologists have already received or may receive denials for the following diagnosis codes:

362.35            central retinal vein occlusion

362.36            venous tributary (branch) occlusion

362.83            retinal edema

Lucentis claims including these diagnoses for dates of service on June 22, 2010 through August 31, 2010 denied as “not medially necessary,” must be appealed through the Medicare Appeals Process. Palmetto will not “reopen” these claims through the Reopening process. Ophthalmologists need to submit denied claims using a Redetermination Request. 

The Redetermination/Reopening Request form is available on Palmetto’s website at http://www.palmettogba.com/Palmetto/Providers.nsf/files/Redetermination_Reopening_Form.pdf/$FIle/Redetermination_Reopening_Form.pdf. Be sure to select “This is a 1st Level Appeal (Redetermination)” when you complete the form.

If needed, the FDA approval letter written to Genentech is available at http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2010/125156s053ltr.pdf.

Label prescribing information is found at

http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/125156s053lbl.pdf

Palmetto should accept a single redetermination that includes all claim denials for these additional three diagnosis codes. When completing the Redetermination form, indicate “see spreadsheet” in the sections related to the individual claim. Create a spreadsheet that includes the required information for each individual patient. At a minimum, your spreadsheet should include the following columns

• Patient’s Name
• Health Insurance Claim Number (HIC) – usually referred to as the patient’s Medicare number
• Date of Service
• CPT/HCPCS code(s)
• Claim Number (ICN) – this number is found on the Medicare Remittance Advice and indicates the claim number Medicare assigned to the specific claims

Please advise the OOS if you continue to experience problems submitting claims with the additional diagnosis codes describing FDA indications for Lucentis.