Wiki MEDICARE COVERAGE FOR BIOPSIES

[warrenfamily103@gmail.com]

Hello,

I am hoping to get some clarification on whether a patient can have a breast biopsy and an underarm/lymph node biopsy on the same day. We are the PCP but the patient called and told us the imaging facility was making her schedule two separate dates because her insurance won't cover them to be done on the same day. She has Humana Medicare. Is this true that they need to be done separate? If so, I would appreciate any direction on where to find this is in writing.

 

[haraml7]

Is the imaging center putting in the clip for the biopsy to then be done by a separate provider. Also, has the patient called her insurance to verify this information. Its sounds incorrect to me, because from a coding point of view these can be coded seperatly for biopsies from the breast and lymph nodes in the same day and will be reimbursed seperatly, So i am taking this as the imaging center is trying to work around something. The patients insurance will tell her the truth on how many biopsies in different anatomical parts of her body can occur per day. I would verify if its just the clips or if they are placing something AND doing the biopsies. I am not sure why an imaging facility would be taking biopsies though they would only do the imaging. So is it the placement of the clip for the breast and the lymph nodes?

 

[thomas7331]

It sounds incorrect to me as well. It doesn't make sense that a payer would require the patient to have two separate procedures on two separate days when it could be done in one sessions. It's not to the benefit of either the payer or the patient. It sounds to me as though the imaging facility has been given incorrect information.

I would escalate this with someone. Providers need to do what's medically necessary and best for their patients and should not be submitting to unreasonable payer requirements. If the payer happens to deny something inappropriately, then it they should be fighting or appealing it - not subjecting the patient to an unnecessary second procedure just to get extra money.