Question BCBS denying malignant excisions as benign?

sinman0531

Networker
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29
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Tampa, FL
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We have recently recieved an influx of denials on malignant excisions for basal cell carcinoma due to the fact that --according to BCBS-- BCC is considered benign "because it is unlikely to metastasize". There is a whole slew of things wrong with this statement, and with the implications on documentation, but has anyone else heard this? Has anyone been able to find a clinical coverage document from BCC addressing this? We have appealed these decisions and according to our 3rd party that handles appeals, the claim decisions are being upheld.
 

trarut

True Blue
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673
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Columbus, OH
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Ummm, that's not for BCBS to decide. I think you need to get your provider rep involved sooner rather than later. BCC is not in ANY way a benign condition and whomever set up those edits in their system is off their rocker.
 

sinman0531

Networker
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29
Location
Tampa, FL
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Ummm, that's not for BCBS to decide. I think you need to get your provider rep involved sooner rather than later. BCC is not in ANY way a benign condition and whomever set up those edits in their system is off their rocker.
Yeah; to be fair we are not 100% sure if it's BCBS, or if it's our 3rd party making stuff up. I found an article from 2018 that was verbatim the explanation we received as the reason for the denial. Our A/R reps are"not allowed" to handle insurance issues, it "has" to be our 3rd party, so we asked for them to get specifics from the plan and copied our RCM on it.
 
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