Wiki UHC Optum denials

[kvo]

We are seeing an increase in denials of the revascularization procedures (37220-37235) after a records review by Optum stating that the procedure is not supported in the document. The dictation of the procedure is detailed and clear so it is confusing why it is being denied. We file a reconsideration with the codes itemized and underlined on the dictation with a supporting letter and any additional records needed. The reconsiderations are even being denied. Is anyone else having this issue? We have not heard or seen any changes needed in documentation for these procedures in any of our resources. Any suggestions are welcome.

 

[Mrsrpc]

UHC can be very difficult to deal with. If they are denying the same codes they used to cover, saying the procedures are "not medically necessary" then look at their current medical policy for that code. Every payer has to put it in their provider portal info (look up Medical Policy Manual or Coverage Determinations). UHC used to follow MCG (Milliman Clinical Guidelines), which is unfortunately proprietary info and very difficult to find in order to fight the denials. Hopefully, you can determine if they follow MCG( look at ALL the verbiage in their denial letters) or if they post their full denial rationale so you can provide the documentation necessary to prove medical necessity. I have had to take them to court, unfortunately.

Of course, if they just expect additional documentation that you have not supplied before, the solution is easy.. just provide it. HTH. Feel free to PM me if you need more info.

 

[dricher1125]

We are seeing an increase in denials of the revascularization procedures (37220-37235) after a records review by Optum stating that the procedure is not supported in the document. The dictation of the procedure is detailed and clear so it is confusing why it is being denied. We file a reconsideration with the codes itemized and underlined on the dictation with a supporting letter and any additional records needed. The reconsiderations are even being denied. Is anyone else having this issue? We have not heard or seen any changes needed in documentation for these procedures in any of our resources. Any suggestions are welcome.

Yes, same codes being denied 372xx for "documentation does not support services billed." I came on here to see what others are saying about the issue. Documentation clearly supports it, and even sending in highlighted notes identifying each procedure, denial is upheld upon appeal, and they're only paying some of the codes on the claim.