TPN Claim Denied by Medicare

Nov 14, 2016

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  1. somarco
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    somarco GA Medicare Expert

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    Client text yesterday. Only have a few details. 37 day hospital stay. Don't know diagnosis. To be discharged Tuesday (tomorrow).

    Requires TPN from a compounding pharmacy delivered by courier at a cost of $172 per day.

    I had no idea what TPN was, so I had to look it up.

    The "juice" can be covered by Medicare under Part B or D.

    https://www.cms.gov/medicare/prescr...nloads/partsbdcoveragesummarytable_041806.pdf

    https://www.medicare.gov/coverage/enteral-nutrition-supplies-and-equipment.html

    https://www.chartwellpa.com/pdf/medicare_tpn_checklist.pdf

    Latest text says Corum (local supplier) has tried for 3 weeks to get Medicare to approve coverage. Denied because she "didn't have the right kind of surgery"

    That is all I know.

    She needs TPN to live. Can't afford $172 per day. She needs the liquid nutrition "indefinitely".

    Can't say if that means until she get's better, runs out of money or dies.

    First time I have encountered anything like this. Would appreciate insight from folks who have had this before, how did you/your client handle it, how did you appeal to Medicare.

    TIA
     
    somarco, Nov 14, 2016
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  2. LostDollar
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    LostDollar Guru

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    After looking at your checklist and some of this other information, I don't think you have nearly enough details to provide any kind of help. I think you need more medical details from the client. I also think you need the "specific vocabulary words and codes" used by Medicare in denials to Corum--rather like carefully analyzing an EOB--to try to find the entry points for appeal or a correctly worded re-application.

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    Scan this starting at p3 and see if that with your experience gives you any ideas for approaches:

    https://www.unitedhealthcareonline....e/Nutritional_Enteral_Parenteral_UHCMA_CS.pdf

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    This is older and has more detail than I can begin to digest, but I see possibilities for you in regard to discussions of "permanence" and documentation needed for medicare. Maybe there is something there that will help too--ie some possiblility of help for the client by getting more clear or differently focused physician documentation:

    http://static.abbottnutrition.com/c...on Reimbursement Manual - Interactive PDF.pdf

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    An article:
    http://courses.washington.edu/nutrmgmt/564_ArticlesUsed_07/Wojtylak_SuppLine_MedicareNS_06.pdf

    Blown up version of decision tree by itself:
    https://www.nhia.org/members/documents/CIGNATPNDecisionTree050306.pdf
     
    Last edited: Nov 14, 2016
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