Wiki Predetermination Letter for RFA

[WENDYBHOLLOWAY]

I am in search of examples of a predetermination letter for radiofrequency ablative treatment of the spine - for both the provider and the facility (ASC). It appears lately that some carriers, namely BCBS and UHC, are now performing pre-payment audits for these procedures. We recently had a UHC claim that was denied for medical necessity for both the provider & the facility claim. I appealed both with documentation of the patient's medical record and documentation from UHC's medical policies and won both appeals. We are in the process of implementing a predetermination policy for this procedure and have predetermination forms from each carrier along with a limited patient waiver form. I would like to submit the forms with a letter attached but would like to have a sample letter on file that will be submitted with the predetermination forms.

Appreciate any and all responses ~

Wendy B. Holloway, CPC
Coding and Billing Coordinator
Orthocare Surgery Center
Albany, Georgia

 

[Melissa Harris CPC]

Wendy,

I would also be interested in this information as we have the same issues here. If you could please let me know if you do (you can PM me).

Thank you

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

 

[WENDYBHOLLOWAY]

Melissa -
I've yet to receive any response. If I do or if I'm able to find and/or create one of my own, I will definately get that to you. If by chance you get your hands on one if you would let me as well I would greatly appreciate it.

Thanks
Wendy B. Holloway, CPC
Coding and Billing Coordinator
Orthocare Surgery Center
Albany, Georgia

 

[MarcusM]

In the past, I would create this type of form using the language in the Medicare LCD or in your case, the specific carrier. Since you won your appeals, I would use some of the same language in a generic fashion to cover all patients. This form also allows the patient to know what the procedure is (patient education) and what you are trying to accomplish and lets them know you are fighting for their benefit, BUT their contract with THEIR insurance may not cover these procedures...like ABN.

They are denying RFA's because (per ODG) "conflicting evidence is available as to the efficacy of this procedure and approval of treatment should be made on a case-by-case basis (only 3 RCTs with one suggesting pain benefit without functional gains, potential benefit if used to reduce narcotics). Studies have not demonstrated improved function. Also called Facet rhizotomy, Radiofrequency medial branch neurotomy, or Radiofrequency ablation (RFA), this is a type of injection procedure in which a heat lesion is created on specific nerves to interrupt pain signals to the brain, with a medial branch neurotomy affecting the nerves carrying pain from the facet joints.
Current research: Multiple placebo-controlled trials have been completed on this topic, but these studies all had potential clinical methodologic flaws including the use of non-controlled diagnostic blocks and potential discrepancies in technique of lesioning from that which is currently recommended. (Hooten, 2005) (van Kleef, 1999) (Boswell, 2005) (Leclaire, 2001) (Van Kleef, 1999) (Gallagher, 1994) (van Wijk, 2005) A recent small RCT found that the percutaneous radiofrequency neurotomy treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test. There was significant improvement in quality of life variables, global perception of improvement, and generalized pain. But RF neurotomy was not a total treatment, and it provided relief for only one component of the patients' pain. (Nath, 2008)"

"There should be evidence of a formal plan of additional evidence-based conservative care in addition to facet joint therapy."