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Medical Director's Corner
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Prior Authorization and Durable Medical Equipment
Durable Medical Equipment (DME) is now passing 50% of the total cost of medical care receiving prior authorization in the TRICARE South Region. DME far surpasses hysterectomies, home health, transplants, speech therapy, and bariatric surgery combined. We currently require prior authorization of any DME with miscellaneous code if purchase price is > $500, power vehicle or wheelchair, continuous passive motion device, bone growth stimulator, and patient lift.
As physicians we must pay attention to prescribe the appropriate medical devices and procedures. It is so much easier to grease the squeaky wheel, by giving the patient equipment they want, not necessarily what they need. The patient may demand the best and latest equipment with all the bells and whistles, even if the medical condition doesn’t require them. For example, one beneficiary demanded that his power wheel chair be specially painted candy apple red.
When evaluating the authorization request for DME the HMHS Market Medical Affairs Department looks at the medical necessity using InterQual criteria and supporting medical literature for evidence based analysis to see if the device is experimental or appropriate for the condition. We also confirm whether it is a covered device in the TRICARE system. If the device is not a covered benefit we contact the ordering physician for further options. If none are available HMHS issues a factual denial letter.
If the equipment is covered but does not fit medical review criteria then the case is referred to the Market Medical Director for his input. If the device can not be approved based on the Medical Directors medical knowledge and experience the request is sent to an external medical reviewer of similar medical specialty as the requesting physician for his or her opinion for the medical necessity of the device. The external reviewer approves the request or will offer the requesting physician an opportunity to discuss the case prior to any denial. If the external reviewer determines the device is not medically necessary a denial letter will be issued.
After all this work the patient still has appeal rights that are explained in the denial letter. HMHS performs appeals of factual (coverage) denials and an external reviewer, who was not involved in the original denial, reviews appeals of medical necessity. If the first appeal is upheld, the beneficiary may request an additional reconsideration. TRICARE performs reconsiderations of factual determinations and an independent contractor reviews medical necessity reconsiderations. As you can see this process is quite complex and offers the beneficiary a fair evaluation to receive the appropriate device for their medical condition.
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