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Thread: Is the wording on this Medicare reimbursement form sufficient or not?

  1. #1

    Question Is the wording on this Medicare reimbursement form sufficient or not?

    Greetings!

    I plan on submitting a "Patient Request for Medical Payment form (CMS-1490S)" for some HEELMEDIX Heel Protectors I bought from Amazon.com a few weeks ago. This is my first time ever doing this so I am concerned and worried about how I should word this. A lying and shady 'foot doctor" had told me that he would get me some very good heel protectors and also handle the Medicare paper work. Instead, this charlatan didn't follow through on his word and bought back some worthless and ineffective Foam Liners.

    Anyway, here's how I worded the form so far:
    "Patient has quadriplegia via a spinal cord injury [C5-6, ASIA A] that was sustained several years ago and is non ambulatory as a result. Due to these complications, patient is prone to getting pressure ulcers on the heel's of his foot. Effective pressure relief helps prevent such skin breakdown, and heel protector devices that has "offloading" features (and also counter measures that are designed to prevent 'foot drop') are necessary: Which is why the "HEELMEDIX Heel Protectors" [HCPCS Code: E0191] are deemed appropriate and is the subject of this reimbursement request.

    The supplier of the aforementioned heel protectors is unable to file a claim for those Medicare-covered DME items/s, so the patient is submitting this claim on his own behalf."



    Is this wording sufficient or needs to be changed/edited? If so, then what changes need to be made and how would you word it? Thanks a bunch!

  2. #2
    Good luck. I was never able to get this kind of thing covered for my mother under her Medicare or secondary BCBS. We had to buy out-of-pocket.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

  3. #3
    Senior Member Oddity's Avatar
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    Have you done a Local Coverage Determination lookup for that HCPCS code? It's regionally specific but there are 64 heel/elbow protector products in my region which are classified under that code. HEELMedix isn't on the list. Not classified = not covered, even if the code is valid and covered for your condition. Classified <> automatically covered either. You should do an LCD before you waste too much time. I normally start at dmepdac.com for my Medicare/DME research. Good luck.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  4. #4
    Like KLD already posted, it most likely will not be reimbursed.
    You may stand better chance if you get a Justification letter/Rx order from physician or member of your medical team as well as purchase from a pharmacy or better yet from a DME that accepts assignment for your insurance.

    Also, like posted above my another forum member, if not on list of approved items it will not be reimbursed even from a DME.
    Also, preventable things usually are not covered, only active problems(already have a documenmented in your record of signs of skin pressure/skin breakdown or a active ulcer).
    Ex: like for insurance to cover cost of granulated compression stocking i have to have a active diabetic/venous stasis ulcer at the time of use and obtain from a pharmacy or DME that accepts assignment. But, when used daily to hopefully prevent ulcers they are out-of-pocket costs.

  5. #5
    Quote Originally Posted by UrbanWheeler76 View Post
    Greetings!

    I plan on submitting a "Patient Request for Medical Payment form (CMS-1490S)" for some HEELMEDIX Heel Protectors I bought from Amazon.com a few weeks ago. This is my first time ever doing this so I am concerned and worried about how I should word this. A lying and shady 'foot doctor" had told me that he would get me some very good heel protectors and also handle the Medicare paper work. Instead, this charlatan didn't follow through on his word and bought back some worthless and ineffective Foam Liners.

    Anyway, here's how I worded the form so far:

    "Patient has quadriplegia via a spinal cord injury [C5-6, ASIA A] that was sustained several years ago and is non ambulatory as a result. Due to these complications, patient is prone to getting pressure ulcers on the heel's of his foot. Effective pressure relief helps prevent such skin breakdown, and heel protector devices that has "offloading" features (and also counter measures that are designed to prevent 'foot drop') are necessary: Which is why the "HEELMEDIX Heel Protectors" [HCPCS Code: E0191] are deemed appropriate and is the subject of this reimbursement request.

    The supplier of the aforementioned heel protectors is unable to file a claim for those Medicare-covered DME items/s, so the patient is submitting this claim on his own behalf."

    Is this wording sufficient or needs to be changed/edited? If so, then what changes need to be made and how would you word it? Thanks a bunch!
    The way Medicare works, you would need to have a prescription for the heel protectors from your doctor. Then, the heel protectors would have to be ordered by a Medicare approved supplier, one who accepts Medicare reimbursement as payment. The supplier would have to use the proper Medicare diagnosis and product codes.

    Since you are seeking reimbursement directly from Medicare for the heel protectors you purchased from Amazon, it is doubtful (100% unlikely) that you will get Medicare to pay for them.

  6. #6
    Senior Member Oddity's Avatar
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    Quote Originally Posted by gjnl View Post
    The way Medicare works, you would need to have a prescription for the heel protectors from your doctor. Then, the heel protectors would have to be ordered by a Medicare approved supplier, one who accepts Medicare reimbursement as payment. The supplier would have to use the proper Medicare diagnosis and product codes.

    Since you are seeking reimbursement directly from Medicare for the heel protectors you purchased from Amazon, it is doubtful (100% unlikely) that you will get Medicare to pay for them.

    Sorry for being blunt, but this is mostly misinformation in this context.

    The self-filing process exists SPECIFICALLY so Medicare enrollees can use non-participating suppliers and providers and still use their Medicare benefits (to get themselves reimbursed).

    All you need to do is follow this process to a T:

    https://www.medicare.gov/claims-appe...i-file-a-claim

    Which includes some of the supporting documents you mention, but at no point do Medicare participating providers NEED to be involved. A well informed and motivated enrollee can seek treatment from whomever they desire, and shop wherever they want, so long as they are willing to pay upfront whatever it costs and accept 80% of assignment for the service or supply in return. (Even better, they can negotiate the initial price down below 80% of assignment and make a little coin for their time and risk. That's what DMEs do. Risk because they might get stuck holding the whole bag for a filing error or coverage determination error or something etc). I've managed this a few times successfully and a couple times not. Each time it was because I wanted to see a non-par provider.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  7. #7
    Quote Originally Posted by Oddity View Post
    Sorry for being blunt, but this is mostly misinformation in this context.

    The self-filing process exists SPECIFICALLY so Medicare enrollees can use non-participating suppliers and providers and still use their Medicare benefits (to get themselves reimbursed).

    All you need to do is follow this process to a T:

    https://www.medicare.gov/claims-appe...i-file-a-claim

    Which includes some of the supporting documents you mention, but at no point do Medicare participating providers NEED to be involved. A well informed and motivated enrollee can seek treatment from whomever they desire, and shop wherever they want, so long as they are willing to pay upfront whatever it costs and accept 80% of assignment for the service or supply in return. (Even better, they can negotiate the initial price down below 80% of assignment and make a little coin for their time and risk. That's what DMEs do. Risk because they might get stuck holding the whole bag for a filing error or coverage determination error or something etc). I've managed this a few times successfully and a couple times not. Each time it was because I wanted to see a non-par provider.
    What you explain has not been my experience in trying to get direct reimbursement from Medicare. Good luck to the original poster.

  8. #8
    Senior Member Oddity's Avatar
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    That's fine, and why I try my best to provide links to primary sources that support the things I post.

    e.g. Of the several possible reasons to self-file provided in the filing instructions on the CMS link I included:

    ...your provider or supplier isn't enrolled in Medicare

    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  9. #9
    If you do try this reimbursement route, I would suggest some refinement to your statement.

    "Patient has quadriplegia via (due to) a spinal cord injury [C5-6, ASIA A](Include the ICD-10 Code for your injury level possibly G82.54) that was sustained several years ago (state the exact date) and is non ambulatory as a result.(Remove "as a result)

    Due to these complications,
    (Remove "Due to these complications) patient is prone to getting (remove getting) pressure ulcers on the heel's of his foot.(heels is not possessive, remove the apostrophe and change foot to feet, the plural of foot) Effective pressure relief helps prevent such(such is an unnecessary word here) skin breakdown, and heel protector devices that has (has should be have) "offloading" features (and also counter measures that are designed to prevent 'foot drop') (don't make foot drop a parenthetical reason...make the case for skin protection and foot drop as two, equally important reasons to justify their necessity)are necessary: (Replace colon with a period and start a new sentence) Which is why the (Remove "Which is why the" and start sentence Heelmedix...) "HEELMEDIX Heel Protectors" [HCPCS Code: E0191] are deemed (remove deemed) appropriate (management devices) and is (are)the subject of this reimbursement request.

    The supplier of the aforementioned heel protectors is unable to file a claim for those Medicare-covered DME items/s(item/s)so the patient is submitting this claim on his own behalf."

    Also see Code E0191 in this document: Nordian Medicare Jurisdiction D Non Covered Items
    https://med.noridianmedicare.com/web...ncovered-items
    Last edited by gjnl; 09-22-2018 at 04:27 PM.

  10. #10
    Thanks Oddity, I will look into the LCD info. I'm a total noob at this whole process and didn't know anything about this. :-)

    Quote Originally Posted by Oddity View Post
    Have you done a Local Coverage Determination lookup for that HCPCS code? It's regionally specific but there are 64 heel/elbow protector products in my region which are classified under that code. HEELMedix isn't on the list. Not classified = not covered, even if the code is valid and covered for your condition. Classified <> automatically covered either. You should do an LCD before you waste too much time. I normally start at dmepdac.com for my Medicare/DME research. Good luck.




    Excellent assist, gjnl!!! This is a great foundation to start with because without proper wording things can go nowhere fast as I understand. Do you have a background in English and/or business writing?

    Quote Originally Posted by gjnl View Post
    If you do try this reimbursement route, I would suggest some refinement to your statement.

    "Patient has quadriplegia via (due to) a spinal cord injury [C5-6, ASIA A](Include the ICD-10 Code for your injury level possibly G82.54) that was sustained several years ago (state the exact date) and is non ambulatory as a result.(Remove "as a result)

    Due to these complications,
    (Remove "Due to these complications) patient is prone to getting (remove getting) pressure ulcers on the heel's of his foot.(heels is not possessive, remove the apostrophe and change foot to feet, the plural of foot) Effective pressure relief helps prevent such(such is an unnecessary word here) skin breakdown, and heel protector devices that has (has should be have) "offloading" features (and also counter measures that are designed to prevent 'foot drop') (don't make foot drop a parenthetical reason...make the case for skin protection and foot drop as two, equally important reasons to justify their necessity)are necessary: (Replace colon with a period and start a new sentence) Which is why the (Remove "Which is why the" and start sentence Heelmedix...) "HEELMEDIX Heel Protectors" [HCPCS Code: E0191] are deemed (remove deemed) appropriate (management devices) and is (are)the subject of this reimbursement request.

    The supplier of the aforementioned heel protectors is unable to file a claim for those Medicare-covered DME items/s(item/s)so the patient is submitting this claim on his own behalf."

    Also see Code E0191 in this document: Nordian Medicare Jurisdiction D Non Covered Items
    https://med.noridianmedicare.com/web...ncovered-items

    Thanks everyone for your input too! :-)

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