Wiki Prosthetic denial

[smcglenon]

I have a patient that received a new prosthetic leg, and is covered by Aetna Commercial insurance. They paid for all of the codes except for three: L5312 (base code), L5950, and L5622. The denial read, "this service is denied because it is inappropriately coded based on other claims already received for this patient". They are basing it on his amputation surgery (CPT 27590). Anyone have an idea what's up with that one? The payer couldn't give me anything other than it's denied based on the surgery claim code.

 

[SharonCollachi]

Did the surgical facility bill for a prosthetic in error at the time of the amputation?

 

[sls314]

I have a patient that received a new prosthetic leg, and is covered by Aetna Commercial insurance. They paid for all of the codes except for three: L5312 (base code), L5950, and L5622. The denial read, "this service is denied because it is inappropriately coded based on other claims already received for this patient". They are basing it on his amputation surgery (CPT 27590). Anyone have an idea what's up with that one? The payer couldn't give me anything other than it's denied based on the surgery claim code.

Have you checked the Aetna Clinical Policy Bulletin for Lower Limb Prostheses? It contains coding tables spelling out which combinations of codes meet Aetna's criteria for coverage. Perhaps reviewing this and comparing it to the claims bill will help give some direction on where the conflict might be?

Link to the Aetna bulletin: http://www.aetna.com/cpb/medical/data/500_599/0578.html

 

[smcglenon]

Did the surgical facility bill for a prosthetic in error at the time of the amputation?

Not for these particular codes. They would only bill the surgery, then once the patient has healed they'll start the process for a prosthetic.

 

[smcglenon]

Have you checked the Aetna Clinical Policy Bulletin for Lower Limb Prostheses? It contains coding tables spelling out which combinations of codes meet Aetna's criteria for coverage. Perhaps reviewing this and comparing it to the claims bill will help give some direction on where the conflict might be?

Link to the Aetna bulletin: http://www.aetna.com/cpb/medical/data/500_599/0578.html

Yes, I reviewed that one before I posted. I looked through everything I had hoping to find an answer, so I had to reach out to the experts!
None of the codes are even remotely applicable to a surgery. With all the prosthetic devices we've billed, I've never had this one happen.