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Independent Review- Assistance needed (original issue in the 'No Preauth' thread

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To make a long story short, my complaint to the State Insurance Commission was passed to the State Attorney General's office. I have been working with an investigator and the investigation is winding down and she says this is no longer a billing issue. The patients insurance is not going to pay just because they miscommunicated with us, they are not going to pay because they consider it investigational.

She said the first next step is it will be going for an Independent Review with the patients employer. She said with this the focus is going to shift to ALL ABOUT MEDICAL NECESSITY.

1. She needs for us to be looking at what criteria the industry is doing for this type of procedure
2. We need information that we can present to the IRO, because they can overturn and make his insurance pay but the more documentation we have for this, the better.
3. She said this is where they step in because they (AG's office) to advocate for the patient because in the end they don't want us billing the patient.

I contacted our rep at Amnioband and he sent me this:*1&Cntrctr=331&DocType=Active&bc=AgACAAIAIAAAAA%3d%3d&

I will post what specifically from the link below. This is my first IRO and I would appreciate any pointers of where to look for information that will help us get our claims paid.  That wasn't very short! Thank you!!

Specifically, this is from the link:
Covered Indications:

Chronic Wounds are defined as wounds that do not respond to standard wound treatment for at least a 30 day period during organized comprehensive conservative therapy.

For all wounds, documentation (as outlined in the documentation requirements of the policy) and a comprehensive treatment plan, before initiation of a specialized wound therapy product is required.

For purposes of this LCD a Failed Response is defined as an ulcer or skin deficit that has failed to respond to documented appropriate wound-care measures, has increased in size or depth, or has not changed in baseline size or depth and has no indication that improvement is likely (such as granulation, epithelialization or progress towards closing).

Medicare covers application of skin substitutes to Ulcers or Wounds with Failed Response that are:
•   Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base;
•   Skin deficit at least 1.0 cm² in size;
•   Clean and free of necrotic debris or exudate;
•   Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by physical examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg);
•   For diabetic foot ulcers, the patient’s medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and also reflects medical management for this condition.

Wound healing is impaired by the systemic use of tobacco. Therefore, ideally patients who have smoked will have ceased smoking or have refrained from systemic tobacco intake for at least 4 weeks during conservative wound care and prior to planned bioengineered skin replacement therapy.

Documentation (in the pre-service record) specifically addressing circumstances as to why the wound has failed to respond to standard wound care treatment of greater than 4 weeks and must reference specific interventions that have failed. Such record should include updated medication history, review of pertinent medical problems that may have occurred since the previous wound evaluation, and explanation of the planned skin replacement surgery with choice of skin substitute graft product. The procedure risks and complications should also be reviewed and documented. Documentation of smoking cessation counseling and cessation measures prescribed, if applicable, must also be documented in the patient's record.

Application of a skin substitute graft for lower extremity chronic wound (DFU and VLU) will be covered when the following conditions are met for the individual patient:
•   Presence of neuropathic diabetic foot ulcer(s) having failed to respond to documented conservative wound-care measures of greater than four weeks, during which the patient is compliant with recommendations, and without evidence of underlying osteomyelitis or nidus of infection.
•   Presence of a venous stasis ulcer for at least 3 months but unresponsive to appropriate wound care for at least 30 days with documented compliance.
•   Presence of a full thickness skin loss ulcer that is the result of abscess, injury or trauma that has failed to respond to appropriate control of infection, foreign body, tumor resection, or other disease process for a period of 4 weeks or longer.
In all wound management the ulcer must be free of infection and underlying osteomyelitis with documentation of the conditions that have been treated and resolved prior to the institution of skin substitute therapy. For purposes of this LCD, appropriate therapy includes, but is not limited to:

o   Control of edema, venous hypertension or lymphedema
o   Control of any nidus of infection or colonization with bacterial or fungal elements
o   Elimination of underlying cellulitis, osteomyelitis, foreign body, or malignant process
o   Appropriate debridement of necrotic tissue or foreign body (exposed bone or tendon)
o   For diabetic foot ulcers, appropriate non-weight bearing or off-loading pressure
o   For venous stasis ulcers, compression therapy provided with documented diligent use of multilayer dressings, compression stockings of > 20mmHg pressure, or pneumatic compression
o   Provision of wound environment to promote healing (protection from trauma and contaminants, elimination of inciting or aggravating processes)

The following are considered not reasonable and necessary and therefore will be denied:

Due to the propensity for misuse of skin substitute and biological dressing products, reimbursement may be made only when the medical record clearly documents that these products have been used in a comprehensive, organized wound management program. All listed products, unless they are specifically FDA-labeled or cleared for use in the types of wounds being treated, will be considered to be biologic dressings and part of the relevant Evaluation and Management (E/M) service provided and not separately reimbursed.
•   Partial thickness loss with the retention of epithelial appendages is not a candidate for grafting or replacement, as epithelium will repopulate the deficit from the appendages, negating the benefit of overgrafting
•   Skin substitute grafts will be allowed for the episode of wound care in compliance with FDA guidelines for the specific product (see utilization guidelines) not to exceed 10 applications or treatments. In situations where more than one specific product is used, it is expected that the number of applications or treatments will still not exceed 10
•   Simultaneous use of more than one product for the episode of wound is not covered. Product change within the episode of wound is allowed, not to exceed the 10 application limit per wound per 12 week period of care.
•   Treatment of any chronic skin wound will typically last no more than twelve (12) weeks.
•   Repeat or alternative applications of skin substitute grafts are not considered medically reasonable and necessary when a previous full course of applications was unsuccessful. Unsuccessful treatment is defined as increase in size or depth of an ulcer or no change in baseline size or depth and no sign of improvement or indication that improvement is likely (such as granulation, epithelialization or progress towards closing) for a period of 4 weeks past start of therapy.
•   Retreatment of healed ulcers, those showing greater than 75% size reduction and smaller than .5, is not considered medically reasonable and necessary.
•   Skin substitute grafts are contraindicated and are not considered reasonable and necessary in patients with inadequate control of underlying conditions or exacerbating factors (e.g., uncontrolled diabetes, active infection, and active Charcot arthropathy of the ulcer extremity, vasculitis or continued tobacco smoking without physician attempt to effect smoking cessation).
•   Skin substitute grafts are contraindicated in patients with known hypersensitivity to any component of the specific skin substitute graft (e.g., allergy to avian, bovine, porcine, equine products).
•   Repeat use of surgical preparation services (CPT codes 15002, 15003, 15004, and 15005) in conjunction with skin substitute application codes will be considered not reasonable and necessary. It is expected that each wound will require the use of appropriate wound preparation code at least once at initiation of care prior to placement of the skin substitute graft.
•   Re-treatment within one (1) year of any given course of skin substitute treatment for a venous stasis ulcer or (diabetic) neuropathic foot ulcer is considered treatment failure and does not meet reasonable and necessary criteria for re-treatment of that ulcer with a skin substitute procedure.
CMS has guidance regarding other specialized wound treatment technology and specifically addresses platelet rich plasma systems (e.g., Autologet, Magellan); negative pressure wound therapy devices and electro-magnetic/ultrasound/mist therapies. They are not addressed in this LCD as their role in the treatment of the two major types of lower extremity wounds discussed here is limited. Utilization remains at the provider’s discretion and must be reasonable and necessary. Note that combination therapy with any bioengineered skin substitute (CTP) will be considered not reasonable and necessary.

To be honest this is a very specific issue and we only have pieces.  I will try to provide some tips but it's difficult without knowing more which would be impossible for you to share on a post:

1.  Make sure you have all information available and in an organized format.  Include the claim, any eobs or correspondences from the insurance including denials or requests for information.
2.  If information was requested and sent, have copies of exactly what was sent in.
3.  Have any documentation supporting the service performed, including anything from Amnioband.
4.  Have the provider write a letter/statement explaining what was done, why it was done, and how effective it was.  The statement should explain why this method was used as opposed to other methods that may not be considered experimental. 

That's really all you can do.  Have as much supporting documentation available as possible and then let them do their review.

One thing I didn't see in the original post was the TYPE of insurance plan this is. In the second post I did see mention of Medicare and LCD but I don't want to assume this is Medicare because the first post says review/appeal was done with the state dept of insurance.

With those things in mind, there is a HUGE question that should be answered first as it will determine WHERE your appeal goes and HOW to do it.

Is the plan an ERISA plan? IF it is.. the state dept of insurance and even your state AG office is completely USELESS. ERISA is on the federal level.  If you are unsure if it's ERISA you want to answer the following questions:

1) is this a "GROUP" health plan?
2) If it is a group health plan, is it a church/state/govt entity? If one of those, it's NOT ERISA
3) If it is a group health plan and it's not a church/govt/state plan it IS ERISA.

Here is a HINT.. MORE than 85% of claims you submit on behalf of any provider/entity ARE ERISA and most medical billers don't understand ERISA or how to go about filing an appeal.

It is not ERISA, it is a state group plan, patient is a police officer. Patient has a chronic non-healing diabetic ulcer hole in his foot.

The carrier is Cigna.

I am frustrated because the provider wants to harp on the fact that 4 CSRs told us that the codes were covered and is really not helping me gather information to aid his case for medical necessity.

What other information do you need? I could use some guidance. Thanks.


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