Can I Appeal A Charge Because A Test Was Performed 9 Days Early?

[PeteC]

I just got a bill for a PSA test because Medicare would not pay it.
The reason, last year, for my annual physical, I got the test on 10/19/2015
This year, for my annual physical I got the test on 10/10/2016.
That is 9 days short of "Annual".
Medicare pays for an annual PSA test.
The bill is for $143.10

Does anyone know of this happening?
Can an appeal to Medicare help?
Is there anything special I should say if I file an appeal?

Thanks In Advance
Pete

 

[JC]

You can file an appeal for anything. Its up to medicare to look at the appeal and make a decision. Common sense would think that once Human eyes look at that it should be covered. But this is government so at best I figure your 50/50 in getting it approved

 

[PeteC]

You can file an appeal for anything. Its up to medicare to look at the appeal and make a decision. Common sense would think that once Human eyes look at that it should be covered. But this is government so at best I figure your 50/50 in getting it approved

I'm hoping someone can say that they tried and succeeded or they failed because of certain circumstances.

I have seen that congress required Medicare to pay for annual PSA. Maybe we need to start asking congress why they didn't include a little "leeway".

 

[MBSC]

Appeal and mention "MLN Matters #SE0709" in the appeal. This particular test can be performed anytime during the 12th month. The 365 day rule does not apply.

"Eligibility and Frequency
Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary's 50th birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.
Calculating Frequency
When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.
EXAMPLE: The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed)."
Reference: http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE0709.pdf

 

[PeteC]

Appeal and mention "MLN Matters #SE0709" in the appeal. This particular test can be performed anytime during the 12th month. The 365 day rule does not apply.

"Eligibility and Frequency
Medicare provides coverage of an annual preventive prostate cancer screening PSA test and DRE once every 12 months for all male beneficiaries age 50 and older (coverage begins the day after the beneficiary's 50th birthday), if at least 11 months have passed following the month in which the last Medicare-covered screening DRE or PSA test was performed for the early detection of prostate cancer.
Calculating Frequency
When calculating frequency, to determine the 11-month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.
EXAMPLE: The beneficiary received a screening PSA test in January 2006. The count starts beginning February 2006. The beneficiary is eligible to receive another screening PSA test in January 2007 (the month after 11 months have passed)."
Reference: https://www.cms.gov/MLNMattersArticles/downloads/SE0709.pdf

MBSC,

Thank you so much. This seems to be exactly what I needed.
First I will call Medicare to see if it can be resolved verbally. I may have to track down how I file a claim with "Healthcare Common Procedure Coding System (HCPCS) codes " G0103. That may take action by my Dr.

I will report back here on any and all developments.

Pete

 

[PeteC]

With this info I was prepared to do battle with Medicare. I called and was told the claim was rejected because the Dr. didn't indicate that the test was needed. It is also possible that the lab didn't click the right box when transferring from the Dr.'s script to the 'puter screen. I will be getting a summary statement from Medicare. On the back are questions to answer then I should get a statement from my Dr. and send them in to file an appeal.

And, Medicare said I was eligible for an annual PSA in September just like MBSC's post indicated.

I'll post here if any new problems develop.

Thanks,
Pete