Wiki BCBS unlisted procedures

[Jamie Dezenzo]

Is anyone having any issues with BCBS denying all unlisted procedures and even after appealing on the back end and still denying for "investigational and not medically necessary"

Thanks for any feedback!

 

[capricew]

Your contract has to state how they will pay unlisted codes. If it does not, then you are not going to win the battle. Look at your contract and if it is in your contract then make a copy of that page and put it with your next appeal.

 

[fuga]

In Mass, BCBS - has specific policy to how Unlisted Codes must be appealed. The initial claim will deny with various denial messages 'other CPT available' 'unproven' 'lacks medical necessity', etc. Op Notes and a letter explaining why you have chosen an unlisted code over an established CPT code (ie - Lap vs. Open procedure, etc). We also give them a comparable CPT for comparison (but I don't believe that is required). Check your states webpage to see what those requirements are.

 

[bfontaine]

Also, what exactly were you doing and does the carrier have a policy that calls that particular procedure experimental? If so, you will probably lose. Look on their website in the Provider Administrative Guide and see if there is a written policy about what you are trying to get paid.