General Discussion

Silent Type

(12,299 posts)

22. Absolutly incorrect. Original Medicare has extensive coverage policies. No, the patient won't pay because it'll be

Thu Dec 4, 2025, 03:45 PM

Dec 4

denied if it doesn't meet requirements (docs can appeal), then the patient can decide whether to get the non-covered procedure/service.

It's very appropriate. There are no services on the list that are "life or death." And everyone of them has a Medicare coverage policy, either National (NCD) or Local (LCD which could be as many as 10 states with other states following policy).

A total of 17 types of procedures will now need prior approval. These services are often flagged for being overused or not always medically necessary. Here's what’s on the list:

Electrical Nerve Stimulators (NCD 160.7)
Sacral Nerve Stimulation for Urinary Incontinence (NCD 230.18)
Phrenic Nerve Stimulator (NCD 160.19)
Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease (NCD 160.24)
Vagus Nerve Stimulation (NCD 160.18)
Induced Lesions of Nerve Tracts (NCD 160.1)
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (LCDs L38307, L38312, L38385)
Epidural Steroid Injections for Pain Management (excluding facet-joint injections) (LCDs L39015, L39242, L36920)
Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (LCDs L34106, L38201, L35130)
Cervical Fusion (LCDs L39741, L39762, L39793)
Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
Incontinence Control Devices (NCD 230.10)
Diagnosis and Treatment of Impotence (NCD 230.4)
Percutaneous Image-Guided Lumbar Decompression for Spinal Stenosis (NCD 150.13)
Skin and Tissue Substitutes (general category)
Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (LCD L35041)
Wound Application of Cellular and/or Tissue-Based Products (CTPs), Lower Extremities (LCD L36690)

Look up everyone of those and see how many fraud or abusive billing practices have been filed for the services. I have no problem punishing docs who cheat Medicare and patients with questionable treatments.

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Highlight:

Medicare's new AI experiment sparks alarm among doctors, lawmakers [View all] marmar Dec 4 OP

Kick dalton99a Dec 4 #1

They get paid to avoid providing care Bettie Dec 4 #2

Isn't it, though! (n/t) OldBaldy1701E Dec 4 #5

Traditional WmChris Dec 4 #3

Kicking with DISGUST!!!! Faux pas Dec 4 #4

One Goal Is Likely To Deny Coverage For Diabetes 2 And Its Related... ColoringFool Dec 4 #6

Jeezus. Joinfortmill Dec 4 #8

Any use of AI in a customer service context is to be feared. "Speak to a representative" is my answer to what I want to Martin68 Dec 4 #7

AI learns that there's a reward for denying coverage. SergeStorms Dec 4 #12

AI finds it more cost efficient to let us die faster IronLionZion Dec 4 #19

there is help for patients Nigrum Cattus Dec 4 #9

Could you please elaborate for those of us who are not inclined to readily click links? mahina Dec 4 #13

Wow! Thanks Nigrum Cattus! That's a great source for fighting insurance denials! BComplex Dec 4 #16

The problem isn't the availability of an appeal - Ms. Toad Dec 4 #20

Arizona is a swing state with lots of retirees IronLionZion Dec 4 #10

They will likely never hear about it, or understand it was REPUBLICANS who passed this BComplex Dec 4 #17

If they are looking for fraud and corruption instead popsdenver Dec 4 #11

They want us dead orangecrush Dec 4 #14

Who in the F*** authorized this change?? BComplex Dec 4 #15

Medicare has used private contractors to review claims since at least 1980. The pilot program is limited to 6 states Silent Type Dec 4 #18

Requiring conservative therapy is a Medicare Advantage/Insurance concept - it has no place in Standard Medicare Ms. Toad Dec 4 #21

Absolutly incorrect. Original Medicare has extensive coverage policies. No, the patient won't pay because it'll be Silent Type Dec 4 #22

Gotcha. You believe it is appropriate to force me to choose between Ms. Toad Dec 4 #25

How many of those services have anything to do with diagnosing or managing cancer? Plus, Silent Type Dec 4 #26

It was in my post - a skin graft. Ms. Toad Dec 4 #28

There is a new policy on skin substitutes that removes the incentive for doctors making thousands of dollars off Silent Type Dec 5 #29

Nonsense. Ms. Toad Dec 5 #31

None of those are life threatening conditions. Let's be honest here. No it's not fantasy that it will happen quickly Silent Type Dec 5 #33

And just now would you know "none of those were life threatening' Ms. Toad Dec 5 #34

Because I can read. None of those are life threatening and most are questionable efficacy. Have no problem telling Silent Type Saturday #35

Sorry, but you don't know what those dozens of appeals related to, Ms. Toad Saturday #36

Talking about list of procedures requiring authorization. None of those are life threatening. Silent Type Saturday #37

Except, of course the denial of a skin graft, which delays surgery for an aggressive cancer - Ms. Toad Saturday #38

If you read the procedures listed, it's for BIOENGINEERED skin substitutes, not skin grafts following cancer surgery. Silent Type Saturday #39

Very specific circumstances best known and evaluated by my own doctor, Ms. Toad Sunday #40

Trump's government... LudwigPastorius Dec 4 #23

It's bad enough when some employee at an insurance company who is not a doctor IcyPeas Dec 4 #24

I love the name - WISeR. It's become a cliche to say that every pronouncement by this administration is Orwellian jls4561 Dec 4 #27

Crap UTUSN Dec 5 #30

who needs a "death panel?" rampartd Dec 5 #32