Paraman,
All 33 of my BCG treatments, the last in 2018, were covered under original medicare, paid for by medicare, with the regular 20% paid by my secondary.
Obviously, you were given an Advance Beneficiary Notice (ABN) by your treater stating that medicare MAY not cover BCG. If a billing department is not sure, they may issue an ABN to protect themselves, just in case.
An inexperienced biller with outdated materials may have missed a change in procedure codes effective July 1, 2019. The following article from Medicare (CMS) may help when you have a conversation with the caregivers billing staff.
www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56754
Text
"Due to the current shortage of Bacillus Calmette-Guérin (BCG) for intravesical instillation it may be necessary to maintain ongoing treatment for bladder cancer with this product at less than the Food and Drug Administration (FDA) label dose of 81 mg (1 vial) per instillation. In response to this situation, Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code by which to report BCG which will allow for reporting of doses less than 1 vial per instillation. HCPCS code J9030
BCG live intravesical instillation, 1 mg becomes effective 7/1/2019 and replaces HCPCS code J9031
BCG intravesical per instillation. HCPCS code J9031
BCG intravesical per instillation will no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be reported with the number of units corresponding to the units being equal to the number of milligrams actually instilled per treatment, as the unit equals 1 mg for the new code."
Read the full article. REMEMBER, billing and coding changes happen frequently. Try to work WITH the biller, avoid all disagreement and arguement. Tell the biller that a friend has had original medicare pay all but the medicare copay/deductible/share of cost - see if you can get this cleared up quickly.
Good luck !
Best
Jack
