Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted post-payment review of claims for Medicare Potentially Unnecessary Surgeries billed on dates of service from January 1, 2020, through December 31, 2020. Below are the review results:

Background

Medicare coverage for hysterectomies, sterilizations and related surgeries is limited to those performed as a necessary part of the treatment of an illness or injury, such as the removal of diseased ovaries, uterus, or testes due to malignancy. However, when the primary indication for these procedures is sterilization, they are not medically necessary and are non-covered under Medicare.

The SMRC identified a potential vulnerability for claims billed with Current Procedural Terminology (CPT) code 58571, laparoscopic total hysterectomy for uterus 250g or less.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of laparoscopy total hysterectomy for uterus 250g or less claims. The SMRC performed medical record review on supporting documentation to determine if the hysterectomy was reasonable and necessary.

Common Reasons for Denial

• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Medical Necessity
  • The Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a) provides the guidance that:
    “No payment may be made under part A or part B for any expenses incurred for items or services which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Claims were denied when submitted documentation did not support that the hysterectomy was reasonable and necessary.
  • Medicare National Coverage Determination (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 230.3 states:
    “Payment may be made only where sterilization is a necessary part of the treatment of an illness, e.g., removal of a uterus because of a tumor, removal of diseased ovaries.”
• Incomplete and/or Insufficient Documentation
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. Documentation submitted was not sufficient to support medical necessity.

Resources

Social Security Act (SSA) Title XVIII,

• § 1812. Scope of Benefits.
• § 1815(a). Payment to Providers of Services.
• § 1833(e). Payment of Benefits.
• § 1833(t). Prospective Payment System for Hospital Outpatient Department Services.
• § 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.

Code of Federal Regulations (CFR) Title 42,

• § 410.28 Hospital or CAH Diagnostic Services Furnished to Outpatient’s: Conditions.
• § 410.32 (d)(2) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• § 410.64 Additional preventive services.
• § 411.15(k)(1). Particular services excluded from coverage.
• § 416. Ambulatory surgical services.
• § 424.5(a)(6). Basic conditions.

Medicare National Coverage Determinations (NCD) Manual, Publication 100-03,

• Chapter 1, Part 4, § 230.3. Sterilization.

Medicare Benefit Policy Manual, (MBPM), Publication 100-02,

• Ch 6, § 20. Hospital Services Covered Under Part B.
• Ch 16, § 20. Services Not Reasonable and Necessary.

Medicare Claims Processing Manual, (MCPM), Publication 100-04,

• Ch 23, § 10. Reporting ICD Diagnosis and Procedure Codes.

Medicare Program Integrity Manual, (MPIM), Publication 100-08,

• Ch 3, § 3.2.3 Requesting Additional Documentation During Prepayment and Postpayment Review.
• Ch 3, § 3.2.3.2. Time Frames for Submission.
• Ch 3, § 3.3.2.1. Documents on Which to Base a Determination.
• Ch 3, § 3.3.2.4. Signature Requirements.
• Ch 3, § 3.6.2.1. Coverage Determinations.
• Ch 3, § 3.6.2.2. Reasonable and Necessary Criteria.
• Ch 3, § 3.6.2.3. Limitation of Liability Determinations.
• Ch 3, § 3.6.2.5. Denial Types.

Last Updated Dec 19, 2022