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Payer deems information provided does not justify or support the level of service that was billed

M

mearnest

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7
Location
Monroeville, NJ
I am hoping to connect with anyone who maybe having similar denials from payers. We sumbitted claims and medical records to support the services provided, however some payers are stating we are not using the most appropriate code. Of course they will not tell us their rational and we should consult the AMA and CMS. I am seeing this more often on 87798 and althought we provide the documentation they continue to state there is a more appropriate code
 
So we have been having this issue as well especially with United and Humana. I cant remember which insurance company (believe it was Humana) but one of them sent a response to an appeal and in their response, they stated that CPT code 87999 is the most appropriate code to use. So, we have started to send claims with 87999, and of course they deny bc it is an unlisted code, and then we submit medical records. The one insurance company (I believe it was Humana) who had previously sent the response with the CPT code 87999 to use denied this code after submitting all the med recs! We sent an appeal with the response from Humana telling us to use 87999. Still waiting on that response. Also, when we registered with the Dex registry they came back with their recommended code, and it was 87999 as well. This is what we have been recommended to use, and its still not "good" enough.
 
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