Why MA Plans Denies Colonoscopy
Screening interval not met
Prior authorization not obtained
Age does not meet screening criteria
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
Building Your Medical Necessity Argument
Distinguish diagnostic from screening indication
Document symptoms warranting diagnostic colonoscopy
Reference family history or personal risk factors
Note positive screening test (FIT, Cologuard) requiring follow-up
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- USPSTF Colorectal Cancer Screening Recommendations
- AGA Guidelines for Colonoscopy Surveillance
- NCCN High-Risk Screening Guidelines
Relevant CPT Codes
Specialty: Gastroenterology
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