Lumbar RFA

lcole7465

Guru
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213
Location
Toledo, Ohio
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Any input on this would be great....

My provider performed a Lumbar RFA on L4 and dorsal ramus of L5... which should be 64635 since it is one level. The insurance company denied 64635 and approved 64636. The person that does our authorizations explanation is below, the insurance is Anthem Medicare Advantage:

"This was a nightmare with the insurance company. When you ask for authorization, you have to give levels per CPT code. 64635 was L3-4 and 64636 was L4-5. Insurance denied 64635, L3-4, because only one MBB was done on this level because they denied the second MBB at this level. When I explained this to them, they did not care. They approved 64636, L4-5, because 2 MBB’s were done at this level. It is the strangest thing I have ever heard of."


I'm not sure what to do in this situation. I know 64636 is an add-on code and shouldn't be/cannot be billed by itself.
 

LisaAlonso23

Expert
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304
Location
Sherman, TX
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64635 and 64636 are your only options. 64636 is the add-on code for 64635, so denying 64635 is an error. I would call back and hope someone who understands coding answers the phone. Add-on codes may not be billed alone.
 
Messages
226
Location
Albany
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I do not understand how they can approve an add on code because it cannot be billed alone. Insurance policy probably requires a positive dual MBB block in order to go to RFA. I would check policy and make sure that you are blocking the levels as they dictate before requesting authorizations for RFA. If you did block the L3-4 per policy then I would appeal with the auth department. Was the service already provided? Sometimes insurance companies do not understand the levels injected.

Melissa Harris, CPC
The Albany and Saratoga Centers of Pain Management
 
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