Mue's for 95165

mistyw0819

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My office has just started receiving denial for medically unlikely amount of units on the code 95165 with BlueCare & BlueCare Select. Can not find where there has been a change of allowed amounts and all other BlueCross plans are paying as usual. When I do claim estimate, it will allow up to 30 units. Has anyone else had an issue? Provider rep was not much help.

Thanks.
 
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I believe there are some BCBS coverage guidelines as far as how many times a patient can be treated within a specific timeframe for a specific number of units. Something along the lines of a total of 60 units within 2 months for example. So as I understand it, it's not necessarily the number of times you bill 95165, but rather the number of units in total that a patient receives, separate or in intervals over that time span. Anything above that units/time span limit gets denied as medically unnecessary. I'm sure there's also some language about when it may be considered necessary. I believe you can appeal that denial if there's an appropriate reason to justify it. Not 100% sure about the specifics and for which BCBS carriers it applies to, but it's the same basic idea for the carriers that do have such a policy.
 

jvanbk

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MUEs for 95165

Frequently BCBS will require a Certificate of Medical Necessity signed by the prescriber for more than the allowed number of units. See if that will increase the number of units that you can be paid for.
 
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