UHC cervical epidurals and radiculopathy

lburns23

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UHC recently changed their policies for my region (Arizona) so cervical (and cervicothoracic) radiculopathy (M54.12 and M54.13) are not covered diagnoses for a cervical transforaminal epidural or interlaminar injection (64479/64480 and 62321). Radiculopathy is a covered diagnosis for thoracic, lumbar, and sacral TFE/ILs, so I feel like certainly they just made a mistake! They also now no longer support cervical stenosis (M48.02) but will cover stenosis, site unspecified (M48.00). How do I go about trying to get UHC to see the error of their ways?
 
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thomas7331

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UHC recently changed their policies for my region (Arizona) so cervical (and cervicothoracic) radiculopathy (M54.12 and M54.13) are not covered diagnoses for a cervical transforaminal epidural or interlaminar injection (62321 and 64479/64480). Radiculopathy is a covered diagnosis for thoracic, lumbar, and sacral TFE/ILs, so I feel like certainly they just made a mistake! They also now no longer support cervical stenosis (M48.02) but will cover stenosis, site unspecified (M48.00). How do I go about trying to get UHC to see the error of their ways?
Having worked for UHC in the past, my expectation is that getting them to admit to an error and change a policy would be massive undertaking. But part of the reason for that is that they're also very careful and thorough when they write these things, and so making a change would require going through their whole review process all over again.

My guess is that there's a reasoning behind this. Can you send a link to the particular policy that impacts you so that we could take a look and see?
 

lburns23

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Having worked for UHC in the past, my expectation is that getting them to admit to an error and change a policy would be massive undertaking. But part of the reason for that is that they're also very careful and thorough when they write these things, and so making a change would require going through their whole review process all over again.

My guess is that there's a reasoning behind this. Can you send a link to the particular policy that impacts you so that we could take a look and see?
This is the commercial plan policy as an example. Thank you for your insight!
 

lburns23

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The policy states "The following are proven and medically necessary: • Epidural Steroid Injections (ESI) for treating radicular pain caused by spinal stenosis, disc herniation, degenerative changes in the vertebrae" but they don't have cervical radiculopathy or cervical stenosis 🥲
 

thomas7331

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The policy states "The following are proven and medically necessary: • Epidural Steroid Injections (ESI) for treating radicular pain caused by spinal stenosis, disc herniation, degenerative changes in the vertebrae" but they don't have cervical radiculopathy or cervical stenosis 🥲
Yeah, I see what you mean, it doesn't make a lot of sense. From the language and some of the code selections in the list, it leads you to think they are looking for specificity to indicate the source of the nerve root pain, but then why would they include a code like M48.00 if that was the case. I don't know that there much you can do about it, but if it you have claim denied because the medical records show that the policy language would allow it but the codes are just missing, then you certainly have grounds for an appeal.

I seem to recall from when I worked there that the medical policy teams did have research analysts that would handle queries from outside. I'm not sure how you could get connected with them but maybe if you called customer service or spoke to your network rep they could give you contact information. But even if so, I probably wouldn't invest too much effort into it - I know that changing policies for an organization this size doesn't happen easily and you're probably going to have to just live with it in the short term. Who knows, they may fix the problem on their own in the next revision.
 

lburns23

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Yeah, I see what you mean, it doesn't make a lot of sense. From the language and some of the code selections in the list, it leads you to think they are looking for specificity to indicate the source of the nerve root pain, but then why would they include a code like M48.00 if that was the case. I don't know that there much you can do about it, but if it you have claim denied because the medical records show that the policy language would allow it but the codes are just missing, then you certainly have grounds for an appeal.

I seem to recall from when I worked there that the medical policy teams did have research analysts that would handle queries from outside. I'm not sure how you could get connected with them but maybe if you called customer service or spoke to your network rep they could give you contact information. But even if so, I probably wouldn't invest too much effort into it - I know that changing policies for an organization this size doesn't happen easily and you're probably going to have to just live with it in the short term. Who knows, they may fix the problem on their own in the next revision.
Thank you - I will make my appeals based on the terminology in the policy, and will try to get a hold of my provider rep. I really appreciate the advice!
 
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