Allegation of Pre-existing Conditions

40.12 – Allegation of Pre-existing Conditions (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) In some cases, the amount of the overpayment is questioned on the grounds that services included in the calculation were for pre-existing conditions and should be omitted from the overpayment calculation. When a beneficiary has filed suit for accident-related services, including services relating to exacerbation of an underlying condition as the basis for the complaint, the total amount of Medicare’s payments should be used to calculate the amount of Medicare’s recovery. The fact that the settlement, or other documentation provides that all parties considered such services to be unrelated to the accident or injuries, does not justify omitting them from Medicare’s recovery.