Physician Services

Rationale for the Referral: The ALJ erred in finding the pulsed radiofrequency nerve ablation (PRF) services were medically reasonable and necessary without considering Medicare Program Integrity Manual guidance setting forth criteria for determining whether services are safe and effective based on authoritative evidence.  Additionally, the ALJ erred in finding the services could be paid with CPT codes 64622, 64623, and 64640. Authoritative coding instruction from the American Medical Association expressly instructs users to code PRF services with unlisted code 64999.

Referral Document

Appeals Council Decision

Rationale for the Referral:  The ALJ erred in allowing coverage without determining whether off-label use of the anticancer drug met conditions of 1861(t)(2) of the Act and implementing guidelines set forth in the Medicare Benefits Policy Manual.

Referral Document

Appeals Council Decision

Rationale for the Referral: The contractor’s LCD for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L29276), states that, except in limited circumstances, 92250 (fundus photography) and 92133 (scanning computerized ophthalmic diagnostic imaging (SCODI) services) “are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease.” The ALJ erred in allowing separate reimbursement for CPT code 92133 without considering coverage indications and requirements set forth in the applicable LCD.

Referral Document

Appeals Council Decision

Rationale for the Referral: The ALJ erred in adjudicating an “issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a carrier has sole responsibility under Part B such as the establishment of a fee schedule,” contrary to 42 C.F.R. § 405.926(c). Additionally, the ALJ’s decision that WPS had not established a rate of general applicability is not supported by the preponderance of evidence in the record.

Referral Document

Appeals Council Decision

Rationale for the Referral: The regimen of Abraxane and Gemzar for pancreatic cancer is supported by a NCCN 2B recommendation, which is defined as “based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate. Thus, a category 2B recommendation in the NCCN is evidence of a medically accepted indication supported by a citation in an approved compendium. The ALJ’s decision is binding.

Referral Document

Appeals Council Decision

Rationale for the Referral: The ALJ did not err as a matter of law where an optometrist furnished central nervous system assessments to diagnose eye problems and neither the applicable LCD nor the CPT code definitions clearly exclude the services from coverage.

Referral Document

Appeals Council Decision

Rationale for the Referral: Medicare Part B payment may not be made to a physician for technical (i.e. nonphysician) components of diagnostic tests when the services were furnished to hospital inpatients.  The Medicare reimbursement is included in the DRG payment made to the hospital for the inpatient stay.

Referral Document

Appeals Council Decision