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Association of American Physicians and Surgeons, Inc.
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Omnia pro aegroto

11/15/99

Marcie Zeccola
Program Inquiries Representative
Upstate Medicare
P.O. Box 5200
Binghamton, NY 13902-5200

Dear Ms. Zeccola:

I have received your letter dated November 11, 1999 (enclosed for your review). You have obviously been grossly negligent in reviewing this claim. You have failed to review and consider all of my arguments presented as I had specifically requested when I asked for review of claims dealing with 93875 performed on the same date of service as 93880. Had you reviewed all of the material that I presented relative to this appeal, including approximately 80 pages sent to Ms. Pat Samson (support specialist) on September 28, 1999, another 80 pages of documentation sent to Ms. Samson on October 2, 1999 and approximately 100 pages of documentation sent to Ms. Sylvia Zampi (Program Representative) on November 2, 1999, you would see that Upstate Medicare is clearly not following Medicare's own "Coding Guidelines" with respect to 93875. As you have failed to consider all the documentation that I sent to Upstate Medicare on this issue, I would DEMAND that you do so at this time. Copies of the documentation can be obtained from your co-workers Ms. Samson and Ms. Zampi. Although you are adept at copying clinically irrelevant information from some bureaucratic source which holds the bizarre view that somehow 93880 is a procedure with "varying levels of complexity" encompassing a totally separate test, done on totally separate arteries, using a totally separate machine such as 93875, I don't know a physician anywhere in the world that would hold this peculiar view. 93880 does not "describe the procedure reported as 93875." These are totally SEPARATE TESTS!

The original decision of "claim denied because this service is not paid separately" is, therefore, INCORRECT based on the following Medicare policy:

You should refer to "EXHIBIT A" of the November 2, 1999 letter and supporting documentation sent to Ms. Sylvia Zampi (Upstate Medicare Program Representative). This refers to the "Medicare Policy on Nonivasive Cerebrovascular Arterial Studies (M-43). You will see that in addition to the "Correct Coding Initiative", it lists "Coding Guidelines" for 93875 (a physiological study as defined on page 1 of the same document). It states clearly "Physiologic studies and a duplex scan would be allowed on the same date of service given the provider can demonstrate medical necessity." I have clearly demonstrated medical necessity in all of the cases that I have presented for appeal. You need to spend time reviewing the text of that letter and the accompanying documentation that I sent in support of my appeal to Ms. Zampi on November 2, 1999. In that letter you will also find documentation that the National contractor for the Correct Coding Initiative wrote me a letter dated October 28, 1999 (See EXHIBIT G of that letter to Ms. Zampi - Nov 2, 1999) stating that the -59 modifier could be used in this situation to designate 93875 as a separate procedure - which it is. Again, you need to spend time actually reviewing the supporting documentation I have provided concerning this appeal which you clearly have not done. My November 2, 1999 letter to Ms. Zampi of Upstate Medicare contains the most up to date information concerning this set of appeals dealing with 93875 and I request that that information be applied to all of my current ongoing appeals.

Furthermore, since I do not agree with your determination, which was based on gross negligence in failure to even read the abundant supporting documentation I sent on this appeal, I request a telephone hearing. Of course, had you actually read my letter to Ms. Samson dated October 2, 1999 regarding this appeal, which you didn't, you would know that. But, for future reference, you may record that I will never accept any adverse determination from the negligent and incompetent staff at Upstate Medicare, and I will always insist on my legal right to a formal appeal. Again, had you actually read my letter and documentation sent on this appeal, you would already know that I have requested a telephone appeal. I, of course, demand that you combine all of the pending appeals in my letters to Upstate Medicare as reference above, now totalling 77 separate appeals dealing with 93875 which will more than reach the necessary $100 required to qualify for a hearing. And, as we continue to send appeals to Upstate Medicare on a weekly basis concerning this wrongful denial of our claims, we will qualify for successively higher levels of appeal should you come to an adverse determination, and I am perfectly willing to pursue the matter in a real court of law if that's what it takes to force Upstate Medicare to follow Medicare's own laws, rules, regulations and guidelines. You may, of course, actually want to review the supporting documentation that I have sent, now totalling over 260 pages, since the information clearly supports my position and you may find it unnecessary and not cost-effective to go through the formal appeal process.

And finally, since you have been grossly negligent in failing to even read the supporting documentation that I have sent on this appeal (as evidenced by your comments in your letter and the fact that you didn't know that I had already requested a telephone appeal in my appeal letter to Ms, Samson), I will be filing a formal complaint against you with the Region II HCFA Office. Physicians deserve better than an incompetent and negligent reviewer who not only isn't qualified to review this type of medical information, but one who doesn't even read the documentation and information sent.

Sincerely,

L.R. Huntoon, M.D., Ph.D.