Wiki Denial CPT - I just recently started

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LaVoncye

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I just recently started working for a pain management provider. I am noticing a large amounts of claims being denied stating the procedures are experimental. What I am noticing is the insurance companies will pay for the first cpt ex. 64634 and deny the rest as experimental. I am see this with Aetna, Cigna and United Healthcare. Prior to my working here these denials were appealed with all the records for treatment leading up to these procedures and they still are denying them. This is also happening with the Facet injections 64493-64495. If any one has any information or can direct please help!!!!!:(
 
Facet Injection Denials

LaVoncye said:
I just recently started working for a pain management provider. I am noticing a large amounts of claims being denied stating the procedures are experimental. What I am noticing is the insurance companies will pay for the first cpt ex. 64634 and deny the rest as experimental. I am see this with Aetna, Cigna and United Healthcare. Prior to my working here these denials were appealed with all the records for treatment leading up to these procedures and they still are denying them. This is also happening with the Facet injections 64493-64495. If any one has any information or can direct please help!!!!!:(
Click to expand...

Facet Injections have specific LCD's with Noridian, and alot of other insurances kind of follow those same guidelines. We get alot of denials for them too, and have to appeal and send notes. According to the rules there are very specific things the provider must do and document. They want to see that the patient has had conservative treatment, such as Physical Therapy, Bracing and drug management for pain. There is a long list of specific rules as far as where the injection takes place, what kind of material is injected, and how many facet injections you can do per session as well as per year, I believe.

The biggest issue with these is that you HAVE to bill it with the appropriate medically necessary diagnosis. For Medicare, this is 721.3, 724.8 (Only if the patient has Facet Syndrome) and 733.82 (Only if the patient has Pseudoarthrosis). I have seen some arguement over whether or not you can code 721.3 for Lumbar Facet Arthopathy, with about 50-50 either direction. I always code 721.3 for Lumbar Facet Arthropathy, and you can find many ICD-9 terminology sites that state that is an alternative term for 721.3. Also, if you look it up using your ICD-9 book, arthopathy leads you to arthritis, and when you choose the lumbar region, it codes to 721.3.

I hope that helps. ?
 
LaVoncye said:
I just recently started working for a pain management provider. I am noticing a large amounts of claims being denied stating the procedures are experimental. What I am noticing is the insurance companies will pay for the first cpt ex. 64634 and deny the rest as experimental. I am see this with Aetna, Cigna and United Healthcare. Prior to my working here these denials were appealed with all the records for treatment leading up to these procedures and they still are denying them. This is also happening with the Facet injections 64493-64495. If any one has any information or can direct please help!!!!!:(
Click to expand...

Now the 64634-64636 are for ablations of the nerve. 1) 64634 is the add on code for the cervical region second level while 64635/64636 are for the lumbar... are you ablating both the cervical and lumbar region? If so, you need to be using 64633 if you are doing one cervical level. If not, the incorrect codes are why they are denying these 2) I have seen some certain Cigna plans that require prior authorization for these procedures.64633-64636) 3) The above is 100% correct about certain diagnosis codes showing medical necesitty 4) Both United Healthcare and Aetna only cover TWO facet injections, any more than that will deny.

I hope this helps!
 
Many other insurances also have medical necessity policies regarding these pain management procedure. Below is a link to Aetna's and United healthcares and an excerpt from the Aetna policy.

http://www.aetna.com/cpb/medical/data/1_99/0016.html
Back Pain - Invasive Procedures
Number: 0016

Policy

Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only 1 invasive modality or procedure will be considered medically necessary at a time.
I.
Facet joint injections (intraarticular and medial branch blocks) are considered medically necessary in the diagnosis of facet pain in persons with chronic back or neck pain (pain lasting more than 3 months despite appropriate conservative treatment).

Facet joint injections (intraarticular and medial branch blocks) are considered experimental and investigational as therapy for back and neck pain and for all other indications because their effectiveness for these indications has not been established.

A set of facet joint injections (intraarticular or medical branch blocks) means up to 6 such injections per sitting, and this can be repeated once to establish the diagnosis. Additional sets of facet injections or medial branch blocks are considered experimental and investigational because they have no proven value.


Link to UHC Policy: https://www.unitedhealthcareonline....roid_and_Facet_Injections_for_Spinal_Pain.pdf
 
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