Wiki Prolia denials

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RebeccaB

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Our claims for Prolia injections given for prostate cancer are being denied...We use dx's C61,M85.9 & Z79.899 which show as cov'd dx's in the NGS medicare policy..

Any info would be much appreciated

Thanks,
Rebecca
 
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Is that the order you are using the diagnosis codes in? If so I would place the M85 code as your primary since it is in fact the reason you are giving the drug. The Prostate code is secondary to that.
 
I have switched the order to M85.9,C61 & Z79.899 and we are still getting denied as not medically neccessary...these exact diagnosis codes are in the policy..I am at a loss
 
One thing to consider is that LCD requirements extend beyond just what diagnosis codes must be on the claim - LCDs often also list requirements for what clinical information must have been documented in the patient's chart to support the treatment. If you submitted records with the claim, or if the payer reviewed records for this patient related to this course of treatment at some time in the past, the denial might have been based on the record review rather than what was on the claim. If that's not the case, then I would only suggesting contacting NGS to get additional information about the denial, or else appealing with records to support compliance with the LCD.
 
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