Help..Medicare rejecting claims for WLS....
As most of you know, Medicare doesn't pre-certify the DS (or any WLS surgery for that matter). Anyway, I fulfilled the medical necessity part by all accounts, referral from my PCP, BMI over 40, more than 100 lbs overweight, several co-morbidities (Type 2 diabetes, hypertension, etc.)
I received the "explanation of benefits" from Medicare today and the claims were rejected by Medicare for my entire surgery and the 2 subsequent surguries that were a result of complications. The reasons stated on the EOB says (a) "the information provided does not support the need for this service or item"; (b) "your claim was reviewed by our medical staff"; (c) "it apprears that you did not know that we would not pay for this service, so you are not liable. Do not pay for this service"
Can someone help me understand what the bottom line of this is? I know I can appeal this, and I plan on doing so. I haven't been in touch with my surgeon's office yet so I don't know what their take on all this is. I had called Medicare with the procedure codes prior to surgery and was told the procedure was covered, if "medically necessary". Could there be more information that maybe the surgeon's office hasn't submitted? I don't know what to make of all of this, but I am a bit freaked out since there are tremendous bills due to the original surgery and the two additional surgeries.
I am on disability and have Medicare and UHC as my secondary. I will not be able to afford the medical bills if my insurances don't cover them. If anybody has any info that could hlp me decipher all this, I would appreciate you input.
Rhonda
DS on 7/7/04
225/163/??