Medicare Appeals –
Limiting the Scope of Review on Redeterminations
and Reconsiderations of Certain Claims
CMS recently provided direction to A/B MACs and QICs regarding the scope of appellate review for redetermination (1st Level) and reconsideration (2nd Level) appeals of certain claims. Historically, MACs and QICs had discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item. Because of that wide discretion, in some cases where the original denial reason was cured, the MAC or QIC’s expanded review of additional evidence or issues resulted in an unfavorable decision for a different reason.
Beginning with redetermination and reconsideration appeals received by the A/B MAC or QIC on or after August 1, 2015, the following scope of appellate review applies:
For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. (But see paragraph (3) below.) Post-payment review or audit refers to claims initially paid by Medicare but subsequently reopened and reviewed by, e.g., a Zone Program Integrity Contractor (ZPIC), Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised, denying coverage, changing the coding, or reducing payment.
If an appeal involves a claim or line item denied on a pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion, and may issue unfavorable decisions for reasons other than those specified in the initial determination.
For appeals of a claim or line item denied on post-payment review because the provider, supplier, or beneficiary failed to submit requested documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, including medical necessity. Claims initially denied for insufficient documentation may be denied on appeal if additional documentation is submitted and it does not support medical necessity.
Contractors will continue to follow existing procedures regarding claim adjustments resulting from favorable appeal decisions. These adjustments will process through CMS systems and may suspend due to system edits. Claim adjustments that do not process to payment due to additional system imposed payment limitations, conditions or restrictions (frequency limits, Correct Coding Initiative edits, etc.) will result in new denials with full appeal rights.
This clarification and instruction applies to redetermination and reconsideration requests received by a MAC or QIC on or after August 1, 2015. It will not be applied retroactively.