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Medicare pre-authorization

Recently, Novitas Solutions has received numerous requests to provide pre-authorization for surgery scheduled to occur within days. Traditional Medicare does not provide pre-certification or pre-authorization of a surgery. Medically necessary services should not be withheld or delayed.

Medically necessary services that have been provided to the patient are billed to Medicare for consideration and processing. If a service is denied, the provider and the patient have a right to request a redetermination of the denial.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meet all technical requirements for coverage, but are determined to be any of the following:

Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used;
Not proven to be safe and effective based on peer review or scientific literature;
Experimental;
Not medically necessary in the particular case;
Furnished at a level, duration or frequency that is not medically appropriate;
Not furnished in accordance with accepted standards of medical practice; or
Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
To be considered medically necessary, items and services must have been established as safe and effective. That is, the items and services must be:

Consistent with the symptoms or diagnosis of the illness or injury under treatment;
Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational);
Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; and
Furnished at the most appropriate level that can be provided safely and effectively to the patient.

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