Wiki CPT 58558 Denied for not proven effective

[Jlobell3@gmail.com]

I have a claim that was billed 58558 and it was denied for "claim/service denied because the procedure/treatment has not been deemed 'proven to be effective' by the payer. Has anyone else seen this denial, and if so, was it appealed and what documentation would be used to support?

Thank you for any help!

 

[sls314]

I have a claim that was billed 58558 and it was denied for "claim/service denied because the procedure/treatment has not been deemed 'proven to be effective' by the payer. Has anyone else seen this denial, and if so, was it appealed and what documentation would be used to support?

Thank you for any help!

Does the payer have a clinical policy online that you can review? I'd start by reviewing to see if the denial was due to the diagnosis code - it's possible that there's a limited range of diagnosis codes it might be covered for.

For example, here is Aetna's Clinical Policy Bulletin that includes CPT 58558: https://www.aetna.com/cpb/medical/data/1_99/0091.html

If it was a diagnosis issue, then the documentation needs to be reviewed to ensure that the diagnosis code supported by the documentation was used on the claim.