Wiki Pro-Disk L Total Disc Replacement HELP!!??

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dzerjav24

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I am trying to get this Pre-certed, and when calling the Ins. Co. I was told that due to the Insurance coverage, a Pre-cert or PA, is not needed. It just has to be deemed "medically necessary" or meet "medical criteria". Well, the pt's symptoms are "medically necessary" or meet our "medical criteria", but the Ins. is being very vague about what they deem necessary or what their criteria is. Does anyone have any advice on how to get a little more information out of the Insurance Co. and also, if this is still considered "experimental or investigational"? The Insurance co. says that it is a billable code, but doesn't need Prior Auth. Idk??? I have spent A LOT of time, looking into this, with no avail. PLEASE HELP!!!???!!???
Thank you SO much in advance! Any advice at this point, would be of help! :confused::mad::(
 
Which is insurance is it? What is the CPT code for the procedure. Sometimes if you give them the CPT and ask them run the code it hit against a policy they have.
 
Coventry ASO, and the procedure code is 22857. I gave the CPT code to the lady I spoke with today, but it seems like every time I call, I get a different answer, but never a direct one. I am new to this, but one would think the Ins. Company could be a little more specific about their criteria. Thank you in advance for your help!
 
dzerjav24 said:
Coventry ASO, and the procedure code is 22857. I gave the CPT code to the lady I spoke with today, but it seems like every time I call, I get a different answer, but never a direct one. I am new to this, but one would think the Ins. Company could be a little more specific about their criteria. Thank you in advance for your help!
Click to expand...

Insurance companies do this intentionally so that providers will just do the procedure.
You need to google search Coventy Medical policy for "total disc arthroplasty". If the person on the phone told you it must meet medical necessity than odds are Coventry has a policy for it. If you cannot find it, then call back and have them walk you through their website to find it. Read it carefully and make sure you have everything they require documented. I also suggest sending the claim on paper with all documentation meeting their medical necessity guidelines as in their policy so as not to delay payment. If you send the claim electronically the first time, they will deny pending medical records from you which only gives them more time to not pay you.

Good luck!
 
Coventry pioneers new ways for providers to deliver quality health care.
•Regional and national network opportunities
•Real-time access to member eligibility, claims and payment info
•Online search options for diagnosis and procedure codes
•Electronic authorization requests and more

Learn more about our provider network in your state. If you're a current provider, log in or register to use directprovider.com today!

http://www.coventryhealthcare.com/

When I go to Coventry's website they state if you are provider you would either login in or register for directproviders.com where you can view procedures codes and do authorization requests. I was unable to access their medical policy without a login or find it on the internet without a login. I would try go thru the prior authorization process with the office notes and MRI or other diagnostic reports. Possibly try to request how to go thru the prior authorization process and submit the procedure and the notes. Or ask where on the website you can view procedures CPT/HCPCS codes that require prior authorization if that is available.
 
http://sites.synthes.com/na/prodisc/medicalprofessionals/Reimbursement/Pages/default.aspx

Reimbursement Assistance: Call 1-800-895-7764

The ProDisc Patient Assistance Line (PAL) works on behalf of patients to petition insurance providers to cover TDR procedures, case-by-case.


​ProDisc_Reimbursement_inset2_15.jpg
​The Payer Relations team identifies insurers who have reviewed multiple TDR claims and works with local surgeons to help them effectively advocate for coverage policies with those insurers.

Above I found on Synthes site, I would call ask if they have any guidance with the insurance company and I would also get the name of the Rep in your area that supplies implant and tell him/her the trouble you are having and they can potentially help connecting you with someone that can help with the prior authorization with this carrier.
 
Thank you both SOOOOOOOOOO very much!!! I am going to try these routes, and cross my fingers....for good measure :) Thanks again, and I will keep you posted on the status of this, for future reference. :)
 
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