Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).  The rules say that use of the appropriate HCPCS code assures that accurate processing can be accomplished resulting in a proper claim determination and reimbursement. The HCPCS is a standardized set of codes used for billing items and services to all payers, including Medicare and Medicaid. The HCPCS is divided into two principal subsystems, referred to as level I and level II. Since 2003, authority has been delegated to CMS to maintain and distribute HCPCS Level II codes.  The DME MACs and the Pricing, Data Analysis, and Coding (PDAC) contractor are responsible for assigning individual DMEPOS products to HCPCS code categories for billing Medicare. When a product has been formally reviewed by the DME MACs or PDAC, the manufacturer is provided with a letter informing them of the correct coding to be used for Medicare billing purposes. Not every HCPCS code has a product classification list; but reviewed products are added to the listings for each code as coding determinations are completed.  For Medicare claim purposes, this product classification listing is accepted as evidence of correct coding. You can find this information on the PDAC website in a DME MAC Joint Publication found at https://www.dmepdac.com/palmetto/PDAC.nsf/DID/J54ATVITZH  The rules state that A recent analysis of upper extremity prostheses claims submitted with the following HCPCS codes revealed incorrect coding of:  L6000 (PARTIAL HAND, THUMB REMAINING) L6010 (PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING) L6020 (PARTIAL HAND, NO FINGER REMAINING)  These codes describe products that are used for three distinct types of amputations including the digit(s) and metacarpal-phalangeal (MCP) joint of missing digit(s).  These products have the capacity for finger opening and closing driven by body-power only.  Body-powered partial hand prostheses are correctly coded when the amputation matches one of the partial hand prosthetic body-powered codes (L6000, L6010, L6020). The base code alone may not fully describe the delivered prosthesis. L-codes referred to as "addition" codes can be used to describe features and functions not found in the base L-code. The available L-codes are either specific to partial hand amputations or to non-specific levels of upper extremity amputations. The use of L-codes with specific amputation levels proximal to partial hand level would be considered incorrect coding.  HCPCS code L7499 (UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used to bill for any features or functions included in the base L-code nor should it be used when a specific L-code exists.  You can find this information on the PDAC website in a DME MAC Joint Publication found at https://www.dmepdac.com/palmetto/PDACv2.nsf/DIDC/1GGI3O2G9G~Articles%20and%20Publications~Advisory%20Articles.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules.