billing 0200T & 0201T

[tboback]

I have billed both of these codes and Medicare has denied as "Procedure/treatment is deemed experimental/investigational by the payer" Claims were appealed with documentation (Op Note and documentation where they have approved these procedures as of July 2009).
The DX codes being billed are 805.6 & 724.6. Any suggestions on a second level appeal to get these paid.

 

[mitchellde]

Was tis one claim or are you speaking of several claims. Were there other codes present? What does the op report state?

 

[tboback]

Actually it was two different claims

One was billed DX 805.6 CPT 0201T
Patient had fallen had terrible low back pain. Procedure "Local anesthetic was placed. Using a trajectory and orders to go to the sacral ala, 2 needles were place and balloons were placed and then cement was placed".


One billed DX 805.6 & 724.6 CPT 0200T
Utilizing the beveled trocar needle, the long axis of the sacrum was cannulated aiming for the sacral promontory on the lataeral view and on the AP being in the middle between the SI joint and lateral aspect of the foramina.The balloon was inserted, inflated, deflated and withdrawn Then articulating needle was advanced and a total of 5ml of Methys methacrylate was injected under fluoroscopic guidance.

 

[tboback]

Actually it was two different claims

One was billed DX 805.6 CPT 0201T
Patient had fallen had terrible low back pain. Procedure "Local anesthetic was placed. Using a trajectory and orders to go to the sacral ala, 2 needles were place and balloons were placed and then cement was placed".


One billed DX 805.6 & 724.6 CPT 0200T
Utilizing the beveled trocar needle, the long axis of the sacrum was cannulated aiming for the sacral promontory on the lataeral view and on the AP being in the middle between the SI joint and lateral aspect of the foramina.The balloon was inserted, inflated, deflated and withdrawn Then articulating needle was advanced and a total of 5ml of Methys methacrylate was injected under fluoroscopic guidance

 

[mitchellde]

Here is what BC says about this procedure:
The use of sacroplasty in the treatment of sacral insufficiency fractures is experimental or investigational as there is a lack of peer reviewed literature demonstrating the effects of sacroplasty on health outcomes. The evidence to date is limited to individual case reports and small case series. No randomized controlled trials regarding its safety and efficacy or improved patient outcomes have been published in the scientific peer-reviewed literature.

If this is BC stance then it is probably Medicares as well.