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Medicare Appeal Packet for Integra® Wound Matrix (Thin)

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Medicare Appeal Packet for Integra® Wound Matrix (Thin) Medicare Appeal Packet for Integra® Wound Matrix (Thin) As a service to our customers, Integra LifeSciences Corporation has assembled this packet of information to assist you with the Medicare appeal process. Included in this packet are as follows: Information on how to appeal a Medicare Claim Determination Sample Letter of Medical Necessity Sample Statement of Medical Necessity Package Insert FDA Clearance Letter Bibliography of clinical articles relative to the Integra® Matrix Family of Products Literature Request Form If you would like to obtain clinical articles to help support the appeal, please contact the reimbursement hotline at 1-877-444-1122, Option 3, option 1 or email the literature request form to [email protected]. Please have readily available, the specific Integra® product that is being appealed and the indication for which the product was used in order for us to provide you with relevant clinical literature. Thank you. Disclaimer: Integra has used reasonable efforts to provide accurate coding advice, but this advice should not be construed as providing clinical advice, dictating reimbursement policy or substituting for the judgment of a practitioner. Integra LifeSciences Corporation assumes no responsibilities or liabilities for the timeliness, accuracy and completeness of the information contained herein. Since reimbursement laws, regulations and payor policies change frequently, it is recommended that providers consult with their payors, coding specialists and/or legal counsel regarding coverage, coding and payment issues. Integra and the Integra logo are registered trademarks of Integra LifeSciences Corporation in the United States and/or other countries. ©2020 Integra LifeSciences Corporation. All rights reserved. T – 1561033 – 1 (2020-04) 1564512 – 1 (2020-04) General Information: Individuals enrolled in Medicare may file an appeal if they believe Medicare should have paid for, or did not pay enough for, an item or service that they received. An individual’s appeal rights are on the back of the Medicare Summary Notice (MSN) mailed to Medicare beneficiaries after they receive services. The MSN explains why a bill was not paid and how to file an appeal. The providers and suppliers of services that file claims on behalf of Medicare beneficiaries may also file appeals. The Medicare Part B Fee-for-Service Appeals Process: Https://www.cms.gov/Medicare/Appeals-and- Grievances/OrgMedFFSAppeals/RedeterminationbyaMedicareContractor Monetary Level of Appeal Type Time Limit for Filing Threshold Appeal Request to be Met First Level Redetermination by a Within 120 days of None Medicare Contractor receipt of the notice of initial determination Second Reconsideration by a Within 180 days from the None Level Qualified Independent date of receipt of the Contractor notice of the redetermination Third Decision by Office of Within 60 days of receipt Minimum of Level Medicare Hearings and of the reconsideration $170 Appeals (OMHA) decision Fourth Review by the Medicare Within 60 days from the None Level Appeals Council date of receipt of the notice of OMHA’s decision or dismissal Fifth Judicial Review in Federal Within 60 calendar days Minimum of Level District Court from the date it receives $1670 notice of the Council’s decision Documentation to include with your Appeal request In an effort to present a solid case to Medicare or any other insurance carrier that the use of Integra® Wound Matrix (Thin) was/is in the best interest of the patient, it is important to submit with the appeal, pertinent health information pertaining to the treatment of the wound. Examples of relevant information to include would be: History and Physical documentation Progress/Office notes specific to the treatment of the wound Operative Reports specific to the treatment of the wound Pictures of the wound Documentation that may illustrate previous wound treatments Letter of Medical Necessity: If a procedure was deemed by the insurer as “not medically necessary,” it may be required that you prove medical necessity as part of your appeal. In addition to providing relevant health information specific to the treatment of the patient’s wound, a Letter of Medical Necessity should accompany the appeal to help further justify the use of Integra® Wound Matrix (Thin). If a Letter of Medical Necessity has been requested, we have available a sample letter, as well as a sample template (on the following two pages) to assist you in the process. Also available, upon request, Integra LifeSciences Corporation can provide you with clinical articles to help support your claim. Please feel free to contact our Reimbursement department at 1-877-444-1122 option 3, option 1 or email the literature request form to [email protected]. For more information regarding Medicare, please go to http://www.cms.hhs.gov/ Disclaimer: Integra has used reasonable efforts to provide accurate coding advice, but this advice should not be construed as providing clinical advice, dictating reimbursement policy or substituting for the judgment of a practitioner. Integra LifeSciences Corporation assumes no responsibilities or liabilities for the timeliness, accuracy and completeness of the information contained herein. Since reimbursement laws, regulations and payor policies change frequently, it is recommended that providers consult with their payors, coding specialists and/or legal counsel regarding coverage, coding and payment issues. Integra and the Integra logo are registered trademarks of Integra LifeSciences Corporation in the United States and/or other countries. ©2020 Integra LifeSciences Corporation. All rights reserved Sample Letter of Medical Necessity: (Please type on physician’s letterhead) Date: << Insurance Company>> <<Address>> <<City, State, Zip Code>> Re: <<Patient’s Name>> Policy Number: << xxxxxx>> Group Number <<xxxxxx>> To Whom It May Concern: Enclosed for your review, are clinical articles documenting the effective use of Integra® Wound Matrix (Thin). The attached Statement of Medical Necessity and information pertaining to <<Patient’s Name>> clinical history and diagnosis clearly demonstrate that Integra® Wound Matrix (Thin) is the treatment of choice. Please send me written verification of coverage and payment for the procedure noted for <<Patient’s Name>> as soon as possible. If you have any questions pertaining to the clinical history or my treatment plan, please call me directly at: <<Office Phone Number>> Thank you for your immediate attention to this matter. Sincerely, <<MD’s Name>> Enclosure: Statement of Medical Necessity Estimate of Professional and Facility Charges Patient Records CC: <<Patient Name>> Medical Record File <<Facility billing contract>> Sample Statement of Medical Necessity for Proposed Procedure Utilizing Integra® Wound Matrix (Thin) PATIENT NAME: _____________________ GENDER: M or F ADDRESS: _________________________ DATE OF BIRTH: _______ _________________________ FACILITY NAME: ______________ PHONE: _________________________ INSURANCE CO: _________________ SUBSCRIBER: ________________ GROUP NAME: ___________________ DATE OF DIAGNOSIS: _________ DIAGNOSIS: ___________________________________________________________ ICD-10 DIAGNOSIS CODE(S): _________________ SIZE OF WOUND: _________ ETIOLOGY OF WOUND: ___________________ DATE OF DIAGNOSIS: ________ DETAILED DESCRIPTION OF WOUND: ____________________________________ ______________________________________________________________________ ______________________________________________________________________ OTHER MEDICAL CONDITIONS: __________________________________________ ______________________________________________________________________ TREATMENT PLAN: ____________________________________________________ ______________________________________________________________________ _____________________________________________________________________ MEDICAL NECESSITY OF USING INTEGRA® WOUND MATRIX (THIN) FOR THIS WOUND: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ PHYSICIAN NAME: (please print) _________________________________________ ADDRESS: ___________________________________________________________ PHYSICIAN SIGNATURE: ___________________________ DATE: _____________ _ Post-Application Integra® Wound Matrix 1. Change the secondary dressing as needed. Frequency of secondary dressing change will Integra® Wound Matrix (Thin) ® be dependent upon volume of exudate produced, type of dressing used and the clinician’s need to inspect the wound bed for signs of infection or healing. DESCRIPTION Note: If hematoma or excess exudate collect under the sheet, Integra® Wound Matrix and Integra® Wound Matrix (Thin) are collagen- small openings can be cut in the sheet to allow fluid to drain. glycosaminoglycan wound dressings that maintain and support a healing 2. As healing occurs, sections of Integra Wound Matrix and Integra Wound Matrix (Thin) environment for wound management. Integra Wound Matrix (Thin) has may gradually peel and may be removed during dressing changes. Do not forcibly remove 50% less collagen compared to each of the corresponding sq cm sizes sections of Integra Wound Matrix or Integra Wound Matrix (Thin) that may adhere to of Integra Wound Matrix. the wound. On inspection, if Integra Wound Matrix or Integra Wound
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