Non Covered vs Not Medically Necessary
What is the difference between a "not covered" denial and a "not medically necessary" denial?
All insurance plans, including Medicare, have services and devices that classified as non-covered benefit. Often times, these services fall into cosmetic or patient comfort categories. In the case of O&P, braces made primarily of elastic or fabric, are not covered. A walking boot used primarily for pressure reduction or lower extremity ulcers is also not covered. In these cases, you may sell the item to the patient directly.
A denial based on medical necessity means the patient's medical condition does not meet the definition of medical necessity for the particular service or device. If the patient's medical records do not support a K3 functional level, a prosthesis billed with L5973 is not medically necessary. In the case of these denials, you are not able to bill the patient.
What Does This Mean for You?
Check the patient's benefit plan to determine coverage. Check the LCD or Coverage Policy to determine the definition of medical necessity.