Oncology & Hematology Coding Alert

Question: Our payer claims IMRT procedures are investigational. How can we prove otherwise?

Texas Subscriber
 
Answer: Unfortunately, an individual carrier can classify procedures, such as intensity modulated radiotherapy plan (77301, Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications), as "investigational."

If the carrier denied your claim because of medical necessity, make sure you are submitting an approved diagnosis code for IMRT procedures. For example, some carriers, such as Trailblazer Health Enterprises in Texas, cover diagnosis code 174.x (Malignant neoplasm of female breast). But other payers, such as Blue Cross Blue Shield, will not pay for IMRT when a practice uses 174.x as the condition.

Key: To move the IMRT off the payer's investigational list, make your case with published information, such as clinical studies, that indicates the procedure provides effective treatment. Generally, you should submit references from clinical trial documents, articles in credible publications (for example, New England Journal of Medicine). You should not, however, submit evidence supplied by the procedure's manufacturer or distributor.

Remember that even when private carriers are secondary insurers to Medicare they can still deny payment for procedures they feel do not meet their policy guidelines. In such situations, you would also submit journal articles and clinical studies on the treatment's effectiveness to change the carrier's policy.