Wiki Radiology Oncology Authorization

[betaba71]

Is anyone else seeing authorization denials for not meeting medical necessity for 77387 (Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed).
When submitting authorization for approval for radiation treatment planning and delivery (77263,77280,77417,77290,77333,77334,77295,77412,77427,77336) all services are being approved but 77387 is being denied as not meeting medical necessity. All cases are for breast cancer and receiving the denials from Allegiance and Evicore but when we try to follow up there is never a valid reason for not meeting medical necessity. Any guidance would be appreciated. Thank you!

 

[sls314]

I just wanted to chime in and mention that there's a Facebook group for radiation oncology coders and billers - if you're interested, you could also ask your question there: https://www.facebook.com/groups/radiationoncologycoders

(I code radiation oncology, but I do the professional fees & am not the one who files for the authorizations. It doesn't surprise me that payers are denying guidance on the authorizations, but I'm not the one working with that firsthand.)

 

[hodgeskm]

Is anyone else seeing authorization denials for not meeting medical necessity for 77387 (Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed).
When submitting authorization for approval for radiation treatment planning and delivery (77263,77280,77417,77290,77333,77334,77295,77412,77427,77336) all services are being approved but 77387 is being denied as not meeting medical necessity. All cases are for breast cancer and receiving the denials from Allegiance and Evicore but when we try to follow up there is never a valid reason for not meeting medical necessity. Any guidance would be appreciated. Thank you!

eviCore Clinical Guidelines, section on IGRT, they indicate IGRT may be used for 3D CRT: "3. During treatment of left breast cancer when a deep inspiration breath hold (DIBH) technique is being used". They lay silent on right breast cancers.

 

[sls314]

This is a timely bump. I'm dealing with a bunch of denied claims for IGRT for breast cancer right now too.

I've been reviewing the Evicore guidelines today. Not super optimistic that the claims will be paid. It looks like the Evicore only allows IGRT for breast cancer for a very limited number of circumstances.

When the facility called to get the auths, they were told authorization wasn't needed under the patient's plan. Of course, the payer still isn't paying for the IGRT anyhow. I'd have rather they denied the IGRT up front before the services than to be wading through all the denials after the fact!