Wiki Effective Appeals

[LuluBarr]

What information do you think is crucial for submitting effective appeals? I am currently appealing Blue Shield's decision to deny one of our patients a cervical facet injection. They requested Medical Record and H & P and after review they said it was not medically necessary...what other things can I submit to prove medical necessity, this really should have been enough!


thank you!

 

[kevbshields]

Because it is a medical necessity denial, a clinician should argue to case in appeal. While there are some coders with the breadth of education and experience to overturn these denials, it is really outside the scope of coders to argue clinical matters.

 

[cobrapam]

I agree with kevbshields. A nurse/physician should be involved in this appeal, at this denial point. You need documentation explaining why this procedure is "Medically Necessary". i.e. Why does the doctor feel this procedure is necessary over non-invasive like pharmacological intervention vs injection, etc. The patient may have already tried a long process before the injection. A clinician can help you with that.

Also, is the diagnosis appropriate for the services rendered. For example, Degenerative Disk Disease vs. neck pain?!? Or it could be a simple 5th digit. Is the dx code to it's highest specificity? DDD, unspecified or DDD, cervical? You didn't say what diagnosis was used so that is just an example. I'm not saying give the patient a diagnosis that's not documented.

If it was a large record, it may be that the payer just didn't take to the time to read every single page. If there is already something in the record / documentation you may need to specifically point that out in your appeal letter. Give them specifics in your letter and point them where to go in the record to back it up.

I am not sure how you initially address denials. But, if you aren't already, you should include a letter with your appeals, specifically addressing the denial. Don't simply make copies of the record/documentation and send it on. The carrier will not take the time to "hunt" for the information. They want it detailed out for them. When I worked denials I always used a letter format along with a copy of the denial EOB and a "copy" of the claim form. If you are seeing this denial as a trend, you may want to do further research on why this is actually being denied. Like above, dx is appropriate for procedure, or contract with carrier requires documentation be sent along with the initial bill every time you bill a specific code.

I could go on all day, but hopefully this will give you a place to start. Don't hesitate to message me if you have any questions, and if it helps to speak in person I would be happy to share my number if you message me.

 

[btadlock1]

To have an effective appeal, you need to have a complete understanding of why it processed the way that it did, so you can find the issue causing the denial. That may sound obvious, but it's not always easy. BCBS has published medical policies on their provider websites with extremely specific guidelines, that all-but-literally spell out exactly what they're looking for when they requested records. (The one you might need is here: http://medicalpolicy.hcsc.net/medic...LICY/data/SURGERY/SUR702.015_2010-07-15#hlink)
In case the link doesn't work:

Facet joint injections that are performed under fluoroscopic guidance may be considered medically necessary according to the *schedule outlined below when the following criteria are met:

The back or neck pain is chronic (i.e., persisting for more than 3 months); AND
Conservative therapy (e.g., physical and/or chiropractic therapy, oral analgesia and/or steroids and/or relaxants, activity modification) fails or is not feasible; AND
No evidence of contraindications, such as severe spinal stenosis resulting in intraspinal obstruction, infection, or predominantly psychogenic pain; AND
The pain is non-radicular (i.e., for patients with a complaint of radiation of pain into an upper or lower extremity), radiculopathy has been ruled out by an MRI, and no signs of dural tension exists (as evidenced by negative "straight leg raise" on physical exam); AND
Suspected spinal facet joint syndrome, as evidenced by low back pain that is exacerbated by extension and by prolonged standing/sitting and that is relieved by rest; AND
Absence of a prior fusion at the clinically suspect levels; AND
Absence of an unexplained neurological deficit; AND
Repeat interventions only upon return of pain and deterioration in functional status.
*Schedule: When the above criteria are met, the following schedule for diagnostic and therapeutic facet joint injection(s) that are performed under fluoroscopic guidance may be considered medically necessary:

1. DIAGNOSTIC PHASE (to determine origin of patient's pain)

A diagnostic block of the joint, or nerves innervating the joints, using a local anesthetic with or without corticosteroids is given initially.
In the diagnostic phase, a patient may receive one (1) injection per level per side in a seven (7) day period to determine the origin of the patient's pain.
If the diagnostic block provides pain relief, therapeutic facet injections are given no sooner than one week after a successful diagnostic block at that spinal region, (i.e., cervical, thoracic or lumbar).
2. THERAPEUTIC PHASE (after the diagnostic phase is completed)

In the therapeutic phase facet joint injection frequency is limited to every two (2) months, provided that each injection yields >50% relief for at least six (6) weeks.
Therapeutic facet joint injections should be repeated only as necessary according to the medical necessity criteria, and are limited to no more than six (6) times per year per spinal region for local anesthetic and steroid blocks.
If therapeutic facet injections are to be performed at a different spinal region:
A positive diagnostic block is required at that region; AND
The therapeutic frequency is limited to every two (2) months per spinal region; AND
Therapeutic improvement is required for additional facet injections; AND
All regions should be treated at the same time whenever possible, provided all procedures can be performed safely.
Facet injections are considered not medically necessary for the following:

When the above criteria are not met; OR
When there is a history of coagulopathy, systemic and/or local infection, or unstable medical conditions; OR
Additional therapeutic facet injections in the absence of an improvement in pain or function; OR
Therapeutic facet injections more frequently than every two (2) months per spinal region; OR
Therapeutic facet injections more frequently than six (6) times per year per spinal region; OR
In the presence of an unexplained neurological deficit.
Ultrasound (US) guidance of either facet or transforaminal injections is considered experimental, investigational and unproven.

You also have to know if there is a specific policy for the patient's group, by asking someone at BCBS.

I'm just speculating, but since the claim was denied post-medical necessity review, that they had a problem with something specific in the record; either they didn't think the documentation met their requirements, or there is an entry that indicates that the procedure is related to something specified in their policy as non-covered. You can find the answer here 90% of the time, even if it's that there's no chance of winning an appeal (which happens pretty often); it's still better to have found out early before wasting a lot of time on appeals and follow-up.

To be honest with you, I've written some successful medical necessity appeals using only my coding books and stuff I found online, but I made sure to stick to official publications from reputable sources, like academics and the government. Your goal is to convince the insurer that you have satisfied the criteria of their medical policy bulletin to the letter, (Include a copy of the policy, too.), and that it's coded correctly, within all of the applicable guidelines. I also have the doctor review the appeal before I send it out, to ensure accuracy, and I always cite my sources in an appeal, with copies of the articles, laws, and guidelines referenced. Good luck!