Wiki Affinity Denying CPT Code 10040 - Acne Surgery

[VivianaP]

I have some claims that Affinity Medicaid has denied for the 10040 (Acne surgery) because the dx code L70.0 (Acne Vulgaris), is saying is not correct or incomplete. Has anybody else received this denial? L70.0 has always been paid with the acne surgery. There is no clinical policy on their website. I asked the rep and they told me to speak to the biller, however I am the biller. There are about 3-4 claims outstanding since Feb 2018. I'm thinking to appeal it with medical records.

Thanks,
Viviana

 

[ellzeycoding]

Some carriers still consider this non-covered or medically unnecessary.

For those that do cover, I don't know of any carriers denying for that particular ICD-10. It's complete and accurate.

Some carriers will consider it medically necessary, only if the patient has responded to other forms of treatment.

Here is Wellcare, for example.

https://www.wellcare.com/~/media/PDFs/CCG/CCG/NA_ALL_CCG_Acne_Procedures_ENG_05_2017.ashx

Acne Surgery
Acne surgery may consist of either of the following:
 Marsupialization; OR,
 Opening or removal of multiple milia, comedones, cysts, and/or pustules

Acne surgery is considered medically necessary when one of the following criteria are met:
 Documented failure of the initial medication treatments (e.g. oral contraceptive hormone therapy, antibiotics,
retinoids) ; OR,
 Documented development of side effects of initial medication treatments.
NOTE: Requests may be approved as long as there is documentation of failed conservative treatment.

 

[AprilSueMadison]

I'm not familiar with Affinity Medicaid. Are they a Medicaid managed care plan for a specific state?

If you are having poor luck getting a policy from Affinity, it may be that they are following one that your local HCA has actually put forth. Affinity looks like it might be in New York, so if that was the case you would review the provider manuals listed on the NY Medicaid website.

 

[JesseL]

Affinity is one of the worst insurance.

They change their prior authorization policies without warning.

I suggest getting prior authorization for everything with them.

Especially things involving ACNE.

Many ACNE medications or treatments are not covered by Affinity.

Affinity sees no medical necessity with ACNE and considers it a cosmetic condition.