Noridian’s Use of Scenarios Questioned

Original story posted on: October 2, 2019

Noridian uses scenarios for the parenteral administration of iron in non-dialysis patients.

The Noridian iron infusion Local Coverage Determination (LCD) is important for just about everyone since Noridian is the Supplemental Medical Review Contractor (SMRC). Noridian could end up reviewing and denying your claims even if you’re not in Noridian’s Medicare Administrative Contractor (MAC) jurisdiction.

Before we address the Noridian iron infusion question, let’s look at another LCD that specifies codes. Novitas has an LCD, number L34960. This LCD specifies conditions for payment for IV rehydration therapy.

Novitas and Noridian both cite authority for their LCDs but omit section 1801 of the Social Security Act, which prohibits contractors from controlling the practice of medicine. Both contractors will say they’re not controlling practice; they’re controlling payment.

The Novitas LCD has only one clinical indication.

Then Novitas goes on with a list of limitations, including frequency limitations. Novitas also has a long list of associated codes that permit IV hydration to be paid. If the associated code is not on the list, it’s not paid. For providers in Novitas’s jurisdiction, it’s actually worse: IV hydration is a targeted probe-and-educate (TPE) code.

The list of diagnosis codes is not exhaustive. Yet, there are myriad reasons a physician may choose IV hydration. If the physician’s reason or diagnosis does not appear on the list of Novitas-approved codes, it’s denied. I’d be shocked if it weren’t an automated edit. Yes, you get appeal rights, but it’s probably a $10 payment, and that’s all for the possibility of referral to other agencies for audit or review.

Now, let’s return to Noridian. The LCD of concern (the number for this one is A55734, in case you’re checking) covers the parenteral administration of iron in non-dialysis patients. The LCD places exactly one diagnostic requirement on providers. It’s only covered for iron deficiency anemia. But, it’s only covered in five broad circumstances of iron-deficiency anemia:

  • Oral supplementation has been tried and patient compliance is inadequate due to gastrointestinal intolerance.
  • Oral supplementation is not possible due to some form of or worsening and underlying GI disorder.
  • Chemotherapy-induced anemia in conjunction with an erythropoietin stimulating agent have been administered.
  • Ongoing iron losses such that oral replacement is inadequate or contraindicated are present.
  • In pregnant patients, iron deficiency is so severe that oral replacement is not feasible without excessive risk to mother or fetus.

These are all going to require the education of physicians and thorough documentation. But the requirements are not significantly different, conceptually, from total knee arthroplasty (TKA) or hyperbaric oxygen therapy (HBO).

It doesn’t fall into a nice tidy list that can be reviewed to ensure payment. But it also doesn’t fall into a nice tidy list for automated denial. The caveat is that Noridian almost certainly has exclusionary diagnosis codes that will result in denials.

I find Noridian’s limitation of the practice of medicine offensive. But in case of a denial, it is much more straightforward to ensure that severe iron deficiency anemia is well-documented and take a chance that eventually an administrative law judge (ALJ) will agree that the scenarios are illustrative, rather than prescriptive or exhaustive.  

Focus on documentation and physician education.

John K. Hall, MD, JD, MBA, FCLM, FRCPC

John K. Hall, MD, JD, MBA, FCLM, FRCPC is a licensed physician in several jurisdictions and is admitted to the California bar. He is also the founder of The Aegis Firm, a healthcare consulting firm providing consultative and litigation support on a wide variety of criminal and civil matters related to healthcare. He lectures frequently on black-letter health law, mediation, medical staff relations, and medical ethics, as well as patient and physician rights.

Dr. Hall hopes to help explain complex problems at the intersection of medicine and law and prepare providers to manage those problems.

This email address is being protected from spambots. You need JavaScript enabled to view it.

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