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No medical necessity

  1. #1
    Default No medical necessity
    Medical Coding Books
    Dear all,

    I got denial from BCBS stating that no medical necessity for the procedure codes 22524, 22840, 72291-26. Then we send medical records,Again the doctor from the insurance said "the service provided has not meet the medical necessity". The patient is 51 yrs female with history of breast cancer now in chemotheraphy. the chief complaint is compression fracture of lumbar. Is there any way to appeal the insurance to get the payment?

    Can anyone clarify this!!!!!!!!!!

  2. Default
    What was the pre-op and post op diagnosis. Also post the operative report.

  3. #3
    Columbia, MO
    I agree with Tonya we need to know what you used for dx codes and what the procedure note stated. If the patient is currently undergoing chemo then her cancer is not history of it is current. Does she have bone metastisis?

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    Below is the kyphoplasty criteria for BCBS of Pennsylvania. Most insurance companies follow the protocol below to determine medical necessity. I would see if I could find the medical policy online for your BCBS and send an appeal with the copy of the medical policy stating why it was medically necessary.

    1. osteoporotic vertebral compression fractures in the cervical, thoracic, and lumbar spine causing moderate to severe pain and unresponsive to conservative therapy (if the osteoporotic vertebral compression fracture is > 8 weeks old, additional clinical and diagnostic criteria are needed [i.e. MRI and evidence of a detailed physical exam] to determine that the fracture is the source of the pain);
    2. painful metastasis and multiple lymphoma or myelomas with or without adjuvant radiation or surgical therapy;
    3. painful vertebral hemangiomas;
    4. vertebral osteonecrosis;
    5. reinforcement of a pathologically weak vertebral body before a surgical stabilization procedure; or
    6. kyphosis.

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