Palmetto GBA became our MAC at the beginning of the year. With that comes their LCD L33445 Removal of Benign and Malignant Skin Lesions with (or in this case without) a different set of "covered" or "deemed medically necessary" ICD-10 codes. This has really shook the physicians in terms of treating lesions that we are used to treating day in and out. They are scratching their head for example as to how/why only a few cyst codes are covered and others are not (specifically Pilar Cyst which they excise quite commonly in our practice). I wondered if anyone would share what your experience is when moving to a new MAC and getting through this transition. What is the recourse when you send in a claim that is automatically hitting an edit? I have a provider who is adamant Pilar Cyst needs to be on the list and asked if I could get someone on the phone for her to speak with about it.

What is the recourse? The appeal chain? Is that what we try to do in order for her to try to appeal to someone’s medical sense to reimburse these claims? I have offered a few suggestions to the physician – for example: Is a pilar cyst more subcutaneous and perhaps Palmetto feels the excisions should be coded with the musculoskeletal codes? She didn’t feel that was appropriate.

I have several questions and claim examples with varying issues but my ground level question at this point is – What do you guys do when this comes up? We can’t just wait and hold out hope that a revision to the LCD comes along that fits our case. We have claims that need to get out the door now.

I’ll appreciate your feedback