Wiki Help Needed -- J9271 denied for CO-B15?

[mmyhand]

My oncology office has received a denial from Humana for Keytruda (J9271) as part of a patient's treatment regimen, citing reason code CO-B15 with the remark "The required initial service for this drug was not processed, received or allowed." J9271 was billed with a clinic visit (modifier 25 appended) along with two pre-medications and CPT codes 96413 and 96375. All other codes on the claim were paid; J9271 was the only denial. Has anyone else seen this denial come up when billing J9271 or other chemotherapy drugs in the office setting? This is the first time I've seen this code denied with that explanation, but I'm unsure what initial service for the drug they could be referring to. Any help appreciated!

 

[bailey@cancerclinic.com]

We have had this denial as well. Did you figure out how to fix it? Any help would be appreciated.

 

[mmyhand]

We have had this denial as well. Did you figure out how to fix it? Any help would be appreciated.

We have not found a surefire way to fix it beyond appeals, and many of them have gone to second-level appeal. I've made multiple calls to Humana, but they've been unable to explain where this denial is coming from or what resource they're using to make it. I know that late last year we received mass denials on chemotherapy supposedly due to a "claims processing glitch" in their system, and I suspect it's something similar here.

My best advice is to appeal the denials with Medicare's billing instructions for chemotherapy drugs and a copy of NCCI edits showing that 99215 is not typically bundled with HCPCS codes. This has seemed to work for in the majority of our appeals. We also had luck with having the patient call Humana member services to question the denial and explain it's causing delays in treatment; we've noticed that Humana will recognize the error and reverse the denial quicker when the patient gets involved, for whatever reason. Hope this helps!