Wiki Appealing "unproven for dx billed" denials

[ollielooya]

Hoping someone in this forum can help. Contracted Commerical insurance carrier. Hip injection with Supartz given. DX code submitted 715.95. Insurance denied with the statement " unproven for dx blled". Accompanying Ultrasound procedure paid, yet the 20610 was denied for above reason. The Supartz AND Injection administration (20610) were assigned to patient responsibility.

Dr. wants to appeal since Supartz isn't covered for hip injections. So, I'll be advising him to retrieve any pertinent clinical studies along with the medical necessity issues for his patient. Since carrier assigned to patient responsibility, it most likely would be in the best interests for doctor to have the assigned representative statement from the patient, so that he can appeal on his behalf, correct? OR, is this necessary since doctor is arguing on the basis of medical necessity even though the insurance says balance goes to patient responsibility?

Just needing a "boost" in order to fashion a creditable and convincing appeal. Where better place to go than to my colleagues on the payer side?

 

[mitchellde]

What you are wanting is not an appeal but an Exception to a medical necessity determination. This needs to be a document/letter composed by the provider which details the medical rationale as to why this drug, this dx, this patient, and the medical benefits achieved.. It should contain numerous references to published clinical data to support his decision to treat this patient with this drug.

 

[ollielooya]

Deborah, thanks for seeing my post and replying. An Exception? I'm trying to find this in the administrative guide, but wouldn't this still be considered an "appeal" by the carrier since this is a followup to their denial? First reconsideration process resulted in denial, and 2nd reconsideration will be fruitless because doctor holds firm to the diagnosis. Would this be considered a contractual issue?
Just stumped as how to proceed forward with this. Your advice concerning medical documentation from a clinical perspective validate what I'm already doing. But your comments regarding an Exception. So....no appeal?

 

[mitchellde]

It is an exception and not an appeal when you have a correct dx code and the denial is due to medical necessity. Unfortunately i have never done this on the back end, we always ask for the exceptions prior to the procedure being performed. An appeal means you have policy issues with the denial, that you can show with documentation that the denial is bogus. What you have here is what i call an expected denial. You should have known that this dx was not considered medical necessity for that drug. So in fact your issue is not with the denial itself. You issue is with the payer not recognizing current medical treatments concerning this dx or drug use.

 

[airart]

ICD9 Code more detailed?

I am thinking the issue lies with the diagnosis code too. 715.95 is very generalized and not more specific. It usually raises flags if you cannot be more detailed on a claim form. Depending on the chart, try to use either 715.15, 715.25, or 715.35.

Did you bill Supartz as J7321?
J7321 -
Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose

Also, if you do an appeal, print the following and attach with your appeal. Most insurance companies follow Medicare Guidelines on coverage and I have won some appeals on this same issue when a managed care carrier didn't cover a service, but Medicare did, they overturned my denial and issued payment. I copy and pasted the below from the Medicare website. I am sure you could find it by putting in the below in search to pull it up. Good luck. PS. I would appeal, and maybe find a more detailed diagnosis as well.

Per Medicare Guidelines:

Intra-articular Injections of Hyaluronan (INJ-033) Billing and Coding Guidelines
Coding Guidelines

1. HCPCS code J7321, J7323, and J7324 are per dose codes. When the injections are administered bilaterally, list J7321, J7323 or J7324 in item 24 (FAO-09 electronically) with a 2 in the unit's field.

J7321
Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose
J7323
Hyaluronan or Derivative, Euflexxa, For Intra-Articular Injection, Per Dose
J7324
Hyaluronan or Derivative, Orthovisc, For Intra-Articular Injection, Per Dose

2. HCPC's code J7325 is defined as 1 mg

J7325
Hyaluronan or Derivative, Synvisc or Synvisc-One, For Intra-Articular Injection, 1mg

When this injection is administered either unilaterally or bilaterally the injections would be billed by placing J7325 in item 24 (FAO-09 electronically) and listing the total number of mg's administered in the units field.

There are 2 different products that are billed using this code.
Synvisc® - (16mg/2ml) – injection is given once a week (i.e., at seven-day intervals) for a total of three injections.

Synvisc-One™- (48mg/6ml) - single dose injection

3. The aspiration and/or injection procedure code may be billed in addition to the drug. Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT 20610). Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.

4. When this drug is administered in the hospital (inpatient or outpatient) setting, the drug/visco supplementation would not be covered by Part B. It would be covered under the Part A benefit.

5. Evaluation and management service:

a. An E&M service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier -25.

b. After the first injection, during the visits for subsequent injections, an E&M service will not be covered unless there was a separately identifiable problem for which the E&M service was required and rendered.

6. When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.

7. If the drug is denied as not reasonable and necessary, the associated injection code is also not covered.

8. We suggest that the entire series of injections be billed on the same claim form.

Revision Effective Date: 01/01/10

Published: Article 02/01/2010; Article 01/01/10; Article 10/01/09; 09/01/09

Revision History:
02/01/2010- Removed code J7325 from coding instruction #1 and added #2, renumbered document.

Annual code updates-Added J7325, Deleted J7322; Added Per JSM 09414 08-13-09 new instructions for hospital billing of Synvisc-One: For services provided between February 26, 2009, through December 31, 2009, contractors shall instruct hospitals to bill for Synvisc-One using three (3) units of the Healthcare Common Procedure Coding System (HCPCS) Code J7322 (Hyaluronan or derivative, Synvisc, for intraarticular injection, per dose). The instructions for billing NOC codes (J3490 and C9399) have been removed. All settings should bill Synvisc-One as 3 units of code J7322.

 

[ollielooya]

Thanks to the two of you for taking time to answer my questions.
Debra, yes this is working from the back end, and since this doctor is relatively new to us, do not think he knew that hip injections with Supartiz (J7321)were disallowed. We've subsequently furnished him the UHC and MCR policy to the practice. So, we're still faced with moving forward and the insurance carrier has told us thru customer support that we need to send in clinical studies, etc, along with everything you mentioned in your first post as an appeal. I do understand what you are saying though.
Airart, thank you also for your suggestions and guidelines furnished. I've read thru them carefully and even with the diagnoses codes you mentioned the denial would not be overturned because these are not on the list of MCR's codes that support medical necessity (at least for WPS-Ill) I don't know who your carrier may be, but are the codes you mentioned considered for reimbursement? Very interesting...Again, thank you both!