Good morning! Hoping I can get assistance with what my next steps should be.
We have a patient we have done the same procedures on 8 times since November.
Before we ever did the procedure, I called multiple times to check to see if authorization was needed. I was told the same thing every time which was all codes are valid and billable no precert required. Two of the codes are covered if medically necessary, notes may be requested to pay claims.
At first, denials were coming in asking for ops notes. They were submitted.
They are Outpatient SX claims. The facility claims are the biggest issue. They are being denied as not covered. but then below that it says, "we have found the service requested is not medically necessary in your case". It then goes on to say "based on current information, coverage cannot be approved because there is insufficient scientific evidence to demonstrate the safety and/or effectiveness of Amnioband for any indication including wound care....Falls under experimental/investigational/unproven, which the customers plan does not cover."
I need advice on what I can do next. (Appeal, have the doctor discuss with a physician reviewer, send claims to a service like Collect RX). This is a first and I'm confused as to how so many CSRs including the preauth department that these codes were covered and do not require precert and then be denied as not covered. Can someone please help me understand? Thank you in advance and if more information is needed, I will do my best.