I apologize for not including the reimbursement list that Angela
Brooks had mentioned in the earlier e-mail. Here is the complete
message, with the list at the end of the document.

Debbie Kelly, Executive Director
Local Coverage Determination (LCD)
For Physical Medicine and Rehab Y-18AB

History:
Trailblazer Health is the intermediary for Medicare in the state of
Virginia. LCDs or local coverage determinations are utilization
management guidelines that Trailblazer uses to communicate billing
requirements and coverage standards for various medical procedures.
When a proposal is made to amend LCD language, it is posted to the
Trailblazer website and a period of time is allotted for
provider/member commentary via the website tools.

Current:
It was brought to my attention that Trailblazer has issued a
proposed LCD impacting Physical Medicine and Rehabilitation to
update the 7/5/2005 LCD. The current LCD (Y-13B-R7) and the
proposed LCD
(Y-18AB) can be found on www.Trailblazerhealth.com. The commentary
period began on 6/29/2005 and will end on 8/15/2005.

Based on the input that I have received, members are unhappy with
the current LCD and are confused and further frustrated by the new
proposed format.

The following list summarizes what appear to be the primary issues
of concern; issues that I urge members to comment to utilizing the
website or postal service (the mailing address is also supplied on
the website). Please note, this is only a summary, other individual
practitioners may note parameters that impact their unique practice
situations. If practitioners note that there are statements not
addressed here that would seemingly affect a number of providers,
please feel free to communicate these via the listserv, as well as
via the Trailblazer website.

Angela S. Brooks, PT
VPTA Payer Relations Specialist



The issues marked * are those that are also included in the original
LCD language and are lingering areas of concern.

1. In the Indications and limitations for Coverage and/or
Medical Necessity, Passive modalities are not defined. Shall
providers defer to the definition in the current PM&R LCD?

2. In the Utilization Guidelines, there are specific services
or procedure numbers (25 and 40) anticipated for various diagnostic
categories. What resources were utilized in developing these
numbers?

3. In the Utilization Guidelines, a maximum of 80 services is
defined per calendar year per member. What options does this leave
for members presenting with more than one diagnosis in a given year?

4. *In the General Modality Guidelines, why is mechanical
traction limited to 25% of the treatment in a given day, whereas
other passive modalities are not limited in this way but rather 25%
for a given treatment course.

5. *In the General PM&R Guidelines treatment time is limited to
30-45 minutes, otherwise additional documentation is required. What
information is this based upon as this does not define the standard
clinical treatment duration?

6. *Iontophoresis is not covered per the General Modality
Guidelines. This is an effective therapeutic procedure. What
information is required to have the reconsidered?

7. In the General PM&R Guidelines does the ordering physician
need to acknowledge his/her awareness of and agreement with the
treatment plan in writing on the 30th day after the initial therapy
evaluation or on or before the 60th day and every thirty days
thereafter? There is contradiction between the verbiage in the LCD Y-
13-BR7 and the proposed LCD Y- 18AB.