CMS issued a special edition MLN Matters meant to be effective August 1, 2015. The guidance reflects CMS instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations of certain claims.
CMS acknowledges its concern that MACs and QICs were using their discretion to conduct appeals to develop new issues. CMS states:
In some cases where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason.
CMS has instructed MACs and QICs to limit their review to the reason or reasons the claim or line item at issue was initially denied.
