Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part B, spinal cord stimulator (SCS), billed on dates of service from January 1, 2018 through December 31, 2018. Below are the review results:

Background

The CMS directed the prior SMRC, Strategic Health Solutions, to perform medical record review of SCS claims. Based on the findings, additional medical review was recommended.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review. Noridian completed medical record review on claims in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Common Reasons for Denial

• Documentation does not support medical necessity
  • National Coverage Determination or Local Coverage Determination. CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 6.2.1, 3.6.2.2, & 3.4.1.3.
• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C 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.
• Documentation does not support the claim as billed
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A and Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual supports denial of claims when the medical record documentation does not support the code being billed.

References/Resources

• Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits
• SSA, Title XVIII, §§1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
• SSA, Title XVIII, §§1869(f)(1)(B). Determinations; Appeals
• SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• SSA, Title XVIII, §§1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
• SSA, Title XVIII, §§1893(h)(4)(B). Medicare Integrity Program
• 42 C.F.R. §411.4. Services for which neither the beneficiary nor any other person is legally obligated to pay
• 42 C.F.R. §404. Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary
• 42 C.F.R. §424.5(a)(6). Basic Conditions
• 42 C.F.R. §24(c). Condition of Participation: Medicare Record Services
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20. Hospital Services Covered Under Part B
• CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 160.7. Electrical Nerve Stimulators
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 20.3. Bundled Services/Supplies
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40.3.6 and 40.3.6.4. Routine Notice Prohibition & ABN Prohibition Exceptions
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs
• Local Coverage Determination (LCD) L34556. Spinal Cord Stimulators for Chronic Pain. Effective 10/01/2015-February 15, 2018
• LCD L35136. Spinal Cord Stimulators for Chronic Pain. Effective 10/01/2015-present
• LCD L35450. Spinal Cord Stimulation (Dorsal Column Stimulation). Effective 10/01/2015-December 31, 2018
• LCD L36035. Spinal Cord Stimulation for Chronic Pain. Effective 10/01/2015-present
• LCD L36204. Spinal Cord Stimulation for Chronic Pain. Effective 06/01/2016-present
• LCD L36879. Spinal Cord Stimulators for Chronic Pain. Effective 03/01/2017-January 28, 2018.
• LCD L37632. Spinal Cord Stimulators for Chronic Pain. Effective 01/28/2018-present
• Local Coverage Article A54817. Spinal Cord Stimulators for Chronic Pain (code guide). Effective 01/01/2016-present

Last Updated Aug 24, 2021