Question for anyone working in New York with emphasis on Orthopedics. We have recently started getting a noticeable influx in denials for CPT 20610 & CPT 20611. The denial reason listed is N425 (statutorily excluded). These are mostly knee injections with a diagnosis of osteoarthritis. Some injections are for hyaluron and some are just for Kenalog, therefore the policies specific to hyaluron would not apply to the injections of Kenalog, but they are all being denied N425.
I know there is a NY Medicaid policy "Viscosupplementation of the Knee: Non-Coverage Decision" from 04/01/2014 which states visco injections will not be paid when billed with a diagnosis of osteoarthritis. However, the UHC Community Plan policy specifically states that in order to be covered the diagnosis Must be osteoarthritis. Since the UHC Community Plan is a Medicaid plan, and they are supposed to follow the same rules as Medicaid, this is a direct contradiction.
We also have the same denials for non visco injections. These are mainly for Kenalog and the billed diagnoses is also osteoarthritis.
We've called UHC several times and the representatives cannot give us a consistent explanation regarding the denials. Some reps have said it was related to the diagnosis, some said it was related to the hyaluron that was injected but they can't seem to give us a consistent explanation. Additionally, those excuses would not be applicable to the Kenalog injections.
If someone else is fighting the same issue, or has obtained a solution, I would greatly appreciate your input or the opportunity to discuss the issue with you.
Thanks in advance for your assistance!
Tina C.
UPDATE:
In case anyone is interested, here is the result of the UHC Community Plan review regarding the denial N425: "There is a PCA in place to deny codes/dx combinations lists. As of 11/07/19 the HP stopped paying for these injections with the DX of osteoarthritis. Per PCA00145068, the HP directed that hyaluronic acid for osteoarthritis of the knee is to be non covered."
This is what they call a "Service to Diagnosis" edit which is a front line edit. If CPT 20610 or 20611 is billed with the diagnosis of osteoarthritis, regardless of what J code is billed with it, it will be denied with the N425 "statutorily excluded" denial. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/EDI-ACE-Smart-Edits.pdf
Because this denial is specific to Hyaluronic (viscosupplementation) injections, any aspirations or injections of other substances are potentially payable upon appeal. We will be appealing a lot of these claims.
FYI: UHC Community Plan is currently retracting payments related to this "new edit" for DOS back in 2018. Based on the document attached, they have made this policy retro-active to an effective date of January 1, 2017, even though they did not establish it until December of 2019.
I hope someone else finds this information helpful.
I know there is a NY Medicaid policy "Viscosupplementation of the Knee: Non-Coverage Decision" from 04/01/2014 which states visco injections will not be paid when billed with a diagnosis of osteoarthritis. However, the UHC Community Plan policy specifically states that in order to be covered the diagnosis Must be osteoarthritis. Since the UHC Community Plan is a Medicaid plan, and they are supposed to follow the same rules as Medicaid, this is a direct contradiction.
We also have the same denials for non visco injections. These are mainly for Kenalog and the billed diagnoses is also osteoarthritis.
We've called UHC several times and the representatives cannot give us a consistent explanation regarding the denials. Some reps have said it was related to the diagnosis, some said it was related to the hyaluron that was injected but they can't seem to give us a consistent explanation. Additionally, those excuses would not be applicable to the Kenalog injections.
If someone else is fighting the same issue, or has obtained a solution, I would greatly appreciate your input or the opportunity to discuss the issue with you.
Thanks in advance for your assistance!
Tina C.
UPDATE:
In case anyone is interested, here is the result of the UHC Community Plan review regarding the denial N425: "There is a PCA in place to deny codes/dx combinations lists. As of 11/07/19 the HP stopped paying for these injections with the DX of osteoarthritis. Per PCA00145068, the HP directed that hyaluronic acid for osteoarthritis of the knee is to be non covered."
This is what they call a "Service to Diagnosis" edit which is a front line edit. If CPT 20610 or 20611 is billed with the diagnosis of osteoarthritis, regardless of what J code is billed with it, it will be denied with the N425 "statutorily excluded" denial. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/EDI-ACE-Smart-Edits.pdf
Because this denial is specific to Hyaluronic (viscosupplementation) injections, any aspirations or injections of other substances are potentially payable upon appeal. We will be appealing a lot of these claims.
FYI: UHC Community Plan is currently retracting payments related to this "new edit" for DOS back in 2018. Based on the document attached, they have made this policy retro-active to an effective date of January 1, 2017, even though they did not establish it until December of 2019.
I hope someone else finds this information helpful.
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