Humana denials on chemo waste based on vial size

mglynn431mglynn431
in DENIALS & APPEALS

Humana is denying payment on our chemo waste based on what size vial we should have used; not what is documented as waste.

Example: We billed for 34 units and 26 units were documented as waste from a 60 mg vial.

Humana is denying to pay for 26 units of waste. Humana states that we should NOT have used a 60 mg vial. According to Humana we should have used a 30 mg vial and a 10 mg vial for the 34 units to be given and we should have billed for only 6 units of waste.

We have filed several appeals and have not received a response.

Is anyone else seeing this trend? Any ideas on how to fight this denial?

Comments

  • trositrosi

    We have received similar denials. Unless there is no smaller vial size manufactured or you can prove that the smaller size was not available or back-ordered, I don't think it can be a successful appeal. Payers want us to use the smallest vials possible to get the dose we need. If someone can offer a successful appeal strategy, I'm all ears.

  • HeatherDuboisHeatherDubois

    Article - Billing and Coding: JW Modifier Billing Guidelines (A55932) (cms.gov)

    https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55932&ver=6


    1. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient, while minimizing any wastage.
      1. For example, bevacizumab (1 unit=10mg) is supplied as 100mg in a 4mL single-use vial or 400mg in a 16mL single-use vial. If the physician administers 300mg of bevacizumab to a patient. The most efficient way to administer this dose is with three-100mg vials. The 300mg is billed as 30 UOS. An incorrect method would be if the physician had utilized the 400mg single-use vial and discarded the remaining 100mg in the vial; as this would not be the most efficient way to minimize drug wastage.
      2. As another example, if the dose of bevacizumab (1 unit=10mg) administered had been 305mg, 31 UOS would have been billed and 9 UOS would have been billed on a separate line with the JW modifier. Note: Providers must round up to the nearest multiple of what one unit of the drug is (e.g. 1 unit is 10mg and if 305mg is administered, providers must round up to the next full unit).


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