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Has anyone had denials from Medicare(NGS) for Simponi Aria max units? Its a edit where Medicare is saying its a medically unlikely event (MUE). Our patient is a larger man and his dose is over 300. For his weight he needed 350 units and medicare denied all of them!!! I have reported to Janssen but knowing how slow the wheels of our government works the doctor had to change his medication.
Yes–I am just reading this now as I see recent postings in NORM about this forum and totally forgot I belong to it since March of this year. I have two letters I can submit to this forum, from ACR to Correct Coding Solutions (they administer the edits) and the Correct Coding Solutions answer to ACR. Basically, Correct Coding went thru AMA to announce posting of these limits for comments–and NO ONE COMMENTED, so it was finalized. It wasn’t until the ACR wrote later on (and outside comment period when this became a known issue), but by then it was too late. Correct Coding even wrote to ACR this was the first they even heard about this objection. Having said this, you can appeal the denial to your MAC with supportive evidence, and if medically necessary they will override the edit. It is also POSSIBLE, but not guaranteed, that a MAC could flag that patient’s claims moving forward so as to override their edit. I am not sure where I can post as attachment on this forum those letters, so Cheri, I will send to you via regular email since you are in my WI team.
We have one large bcbs state health plan (South Carolina) patient that I recently noticed this with. It was done previously last year with her as well, but we appealed it and they paid correctly for almost a year until her last infusion in November. We have appealed again and are waiting on a response. Nilsa, would you mind sharing the letter with me? arthconpa@gmail.com
Hi Everyone I have had trouble logging in to the forum so I am just now getting to respond. I have a patient on 7 vials of Aria with UHC. They pay for 6 and deny the amount for one vial and I have to go online and do a reconsideration EACH time and they do pay it. Janssen rep told me that MC does have an edit so therefore he others do. With my appeal I include their MAX DOSE POLICY which says nothing about Aria having a max dose.
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