Wiki 87505 for GA Healthspring

aamipatel

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I am facing lots of denials on 87505 with cigna Healthsring GA location, stating service not medically necessary. any suggestion in this one? Also having issue with Humana medicare for Procedure code 87506. please help me on them as well. thank you.
 
Im having the same issue. Was hoping I wasn't only one. The medicare policy updated just recently and they removed a TON of prior approved codes for this stool study. I just don't understand
 
I am facing lots of denials on 87505 with cigna Healthsring GA location, stating service not medically necessary. any suggestion in this one? Also having issue with Humana medicare for Procedure code 87506. please help me on them as well. thank you.
Hi aamipatel,
You state that these are happening in the GA location. From my review it appears that Cigna Healthsring is Medicare and Humana Medicare is also. For both procedure 87505 and 87506 in GA both procedures have LCD's again both following Medical Policy #A58710. I would search for the medical policy and validate that what was billed meets medical necessity per Medical Policy. If so, I would appeal.
Thanks,
Dana
 
Hi aamipatel,
You state that these are happening in the GA location. From my review it appears that Cigna Healthsring is Medicare and Humana Medicare is also. For both procedure 87505 and 87506 in GA both procedures have LCD's again both following Medical Policy #A58710. I would search for the medical policy and validate that what was billed meets medical necessity per Medical Policy. If so, I would appeal.
Thanks,
Dana
Thank you Dana. This information might help, I am already following CMS and Cigna policy guidelines, but surely will look to this LCD policy guideline as well. thanks again for the help.
 
From my experience with healthsprings (AL) they will deny if ANY diagnosis listed is unspecified....I am not sure if GA is doing the same thing but I wanted to mention it in case.
 
Hi
CPT 87505 & 87506 are lab test see if pt has infections of Clostridium or Heli Pylori or some bacteria in digestion/stomach area. If provider is testing and this bacteria comes back positive put dx B96.7 or B96.81 which is appropriate. If no results come back then I d put dx on the problem patient is suffering with from provider s note. Disease such as K59, R10, K21, K25 and end with dx Z13.810 or Z01.89.
I hope this data helps you
Lady T
 
Plans are recently denying CPT 87505 as several of our local policies require this service to be performed in the inpatient setting only. They will not reimburse this service if performed in the outpatient setting.
 
Hi
I don t think the CPT 87505 and 87506 would be rejected if done for a EGD procedure in the ambulatory setting. I cannot see these labs done in physician office or clinic OP setting maybe why not reimburse this lab.

Lady T
 
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