Medicare Modifier payment disparity

I haven’t had that specific denial but I can tell you that over the years I have had to fight Medicare and make appeals many, many, times. I eve. Had to fight them all the way to an administrative law judge, once, to get them to pay for my medication since they aren’t allowed to deny you simply because it costs too much. Of course, I won, eventually, but it took almost a year without my meds to do it! All I can recommend is keep appealing higher and higher until you get to a law judge as well if you have to. Let us know if you need help! Keep on keepin’ on, DPM

Hi . The language can certainly be alien. I know that Novitas region refers to an area of the country that Novitas has the contract for administering Medicare. Also "J3262" refers to the drug Actemra (see: https://www.aapc.com/codes/hcpcs-codes/J3262#:~:text=Injection%2C%20tocilizumab%2C%201%20mg%20J3262,HCPCS%20Codes%20%2D%20Codify%20by%20AAPC). In addition modifiers like seen here are used for drugs that have two forms of administration. Actemra can be done by both injection and infusion. The "JA" is for intravenous infusion, while a "JB" would be for subcutaneous injection of the drug (see: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58527&ver=33#:~:text=The%20use%20of%20the%20JA,subcutaneous%20injection%20of%20the%20drug.) All of this seems to be a very complex way of saying that the Novitas Medicare administrator turned down you Actemra infusion. Your doctor should be able to provide more specifics, including any explanation as to why it was turned down. It just shouldn't be this hard for people to get a reasonable explanation on what is happening with their medications and medical claims. Wishing you the best. Richard (RheumatoidArthritis.net Team)