Wiki Vitamin D testing denial for medical necessity

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Idahohappy

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Our local Regence is denying all vitamin D testing, even with the code E55.9 stating it does not meet medical necessity. I have decided to try and appeal those who actually have vitamin D deficiency but what about those who have symptoms necessitating more screening lab like Vitamin D testing? Also, it appears that Regence has the whole charge as a contractual adjustment. Can we really not bill the patient for this lab (some patients request it). We are going to implement an ABN, but if we do not have one, can we still bill the patient? The EOBs are confusing as they list a contractual adjustment amount, and then then they add CO-50 which is the "does not meet medical necessity."
 
dwerry1965 said:
Our local Regence is denying all vitamin D testing, even with the code E55.9 stating it does not meet medical necessity. I have decided to try and appeal those who actually have vitamin D deficiency but what about those who have symptoms necessitating more screening lab like Vitamin D testing? Also, it appears that Regence has the whole charge as a contractual adjustment. Can we really not bill the patient for this lab (some patients request it). We are going to implement an ABN, but if we do not have one, can we still bill the patient? The EOBs are confusing as they list a contractual adjustment amount, and then then they add CO-50 which is the "does not meet medical necessity."
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There are two steps that I'd recommend you take in order to get the answers you're looking for here: The first would be to find and review your local Regence's policy for coverage of this test. If they are denying for medical necessity, then there should be something in writing that explains the criteria they use, i.e. what symptoms or diagnoses support medical necessity or allow coverage. (However, if the test is done as a screening, then you will need to check the individual patients' benefit plans to see if it is a screening that is offered on that particular patient's plan.) You can probably find all of this information on their web site, but if not, they should be able to give it to you or direct you to the correct location if you contact them. The second thing would be to review your provider's contract with the payer - that should tell you when you can or cannot bill the patient for non-covered services, and whether or not you are permitted to use an ABN or other waiver. If you are not contracted with this payer, then you may bill the patient unless they are on a Medicare or Medicaid replacement plan, in which case it is likely not legal to bill them unless you have given them prior notice that you are not participating with that plan. If they have denied the charge as a contractual adjustment, most likely this is due either to your contract or due to the regulations of the Medicare or Medicaid managed care plan.
 
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