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Insurance Coverage Issues

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A HCPCS code is a code used for medical coverage billing purposes.  It classifies a product and gives a “fee schedule” – an amount that the insurance carrier may pay towards the purchase or rental or purchase of certain medical devices, equipment or services.

SADMERC [Statistical Analysis Durable Medical Equipment Regional Carrier] has issued a determination letter stating that the HCPCS code for the TLC® is E0118.  

The E0118 code is for CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, and WITH OR WITHOUT WHEELS. 

Each insurance carrier sets their own fee schedule for a particular HCPCS code.  E0118 does not have a Medicare fee schedule but it is the proper code to use for billing purposes.  We are actively pursuing a more appropriate categorization of our TLC® but this is a lengthy process.

The more documentation the patient gets from their doctor to illustrate the medical necessity of piece of medical equipment, the better chance of getting insurance coverage.  It helps if their doctor can provide a prescription and a letter of medical necessity.  We offer an example of a medical necessity letter that states the equipment is necessary for the patient’s health and recovery. 

Unfortunately, health insurance companies and Medicare/Medicaid agencies differ in the coverage they may or may not provide to their insured.  Please consult your insurance carrier for further information.

CMS (Centers for Medicare & Medicaid Services) has announced that effective April 1, 2008, HCPCS code E0118 will be denied as not medically necessary and will be denied as supplier liable, unless a valid ABN is obtained and the GA modifier is reported on the claim.