Wiki Appeals for Contractual Exclusions

Create Wiki
M

MLamanna9

Guest
Messages
3
Best answers
0
Good Morning
I am a biller at a plastic surgery practice and I need alittle help with an appeal on an Emergency Room surgery that is being denied as contractual exclusion for a cosmetic procedure that the patient had over 10 years ago. The patient presented to the ER with severe back pain shooting down both legs, ASIA syndrome, and had multiple granulomas all through out her buttocks and thighs. We took her to surgery and started to remove the granulomas. There had to be 2 more surgeries to remove them all and close the wounds. The patient was aware that there would be some deformities after the surgery. This by all means was not a cosmetic procedure and we did not perform the orginal surgery 10 years prior. I have written appeals, so has the patient, we have sent before and after photos and included all medical records. We even had a peer to peer and their doctor agrees about medical necessity but is denying for contractual exclusion. They are stating that they do not cover any problems that arise from a cosmetic procedure no matter how long ago it was. I am stumped. Is there somewhere we can appeal over Aetna?? Any government office we can contact??? Any help would be appreciated!!!!

Thank you for any advice you can give!!
 
If this is a fully insured plan, you can contact your state insurance commissioner request that the case be reviewed. My guess though is that by the sound of this, it is probably a self-funded employer group and will be outside the jurisdiction of the state. If so, the patient may wish to try to work with their employer's human resources department and request a contractual exception be made as employers do sometimes grant these. Outside of these options, if you've already been through this many levels of appeals and have exhausted Aetna's process with the peer review, it may be necessary at this point to speak with an attorney to get a legal opinion as to the options, and as to whether or not they think the courts would side with you that the service should have been covered. You won't be able win an appeal of a denial for a contractual exclusion by arguing that a service should be paid because it was necessary for the patient - you will need to have a convincing case that the denial was in error because it should have been a covered service under the legal and contractual terms of the patient's plan.
 
You must log in or register to reply here.
Top