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Posted By lana on 04-24-2007, 14:47:00 in Ob-Gyn
We are being denied by Cigna and Aetna on 51795 - they are saying it is
incidental to other codes; I have lost a 1st level appeal with a letter
from the American Urological Society which describes each CPT code in
detail. Anyone with success in appealing this or should I just move on.
The other codes we use are 51726, 51797, 51772, 51784, 51741.

Thanks.

Comments (12)
Posted By Kimberly on 04-26-2007, 12:22:00
This was for something else, but it was a bundling issue. Seems like any appeal I have with Aetna has to go to 3rd level before being paid.

Kimberly Horn, CPC, BSHA
Dr Shanbour and
Dr Goff
Oklahoma City, OK 73120
405-242-4036
Posted By Cindy on 04-25-2007, 13:53:00
MessageActually, it's related to a bone density with one of the Blues. Two patients on FDA-approved meds for osteoporosis without bone stabilization. Bone densities were done at approximately 16 months apart. Blue is saying that it has to be two years, despite that their initial denial stated "once bone mass changes had stabilized." Do I go to the insurance commissioner? Thank you for any advice. cindy

Was this appeal relating to the urodynamics bundling with Cigna/Aetna or something else?
Posted By lana on 04-25-2007, 12:39:00
Was this appeal relating to the urodynamics bundling with Cigna/Aetna or
something else?
Posted By Kimberly on 04-25-2007, 11:41:00
many times have you appealed it? You should have a third level to send it to that gets it on the medical director's desk. The second letter they sent you should contain an address to send another appeal to.

The last one I sent I told them if it wasn't corrected my next stop would be the insurance commissioner, I had a check 3 weeks later.

Kimberly Horn, CPC, BSHA
Dr Shanbour and
Dr Goff
Oklahoma City, OK 73120
405-242-4036
Posted By Arlene on 04-24-2007, 22:30:00
Then I would talk to someone at your state Medical Association or your state Insurance Commissioners office. These organizations frequently have contacts at the higher level of insurance carriers.
If you have "exhausted" all appeals you may not have any other avenue. But you do not have to wait until you reach this level to ask for assistance from these organizations.

Remember too that the patient is the client of the insurance company, so frequently you can enlist their help in appealing denied claims.
Posted By Arlene on 04-24-2007, 22:21:00
Unfortunately, if Claim Check edits bundle the code, and you signed a contract that you understood they use Claim Check for their coding edits, you are out of luck.
Posted By Cindy on 04-24-2007, 21:23:00
What's your next step when told, "Appeal efforts have been exhausted." A lawyer? cindy
It has been my experience with Aetna, that it can sometimes take going to the third level of appeals to get anything paid. It's like they just have someone sitting there denying the first two and if the providers office takes the time to send it a third time to the medical director then they say "ok lets review it".
Posted By Kimberly on 04-24-2007, 19:59:00
It has been my experience with Aetna, that it can sometimes take going to the third level of appeals to get anything paid. It's like they just have someone sitting there denying the first two and if the providers office takes the time to send it a third time to the medical director then they say "ok lets review it".

Kimberly Horn, CPC, BSHA
Dr Shanbour and
Dr Goff
Oklahoma City, OK 73120
405-242-4036
Posted By lana on 04-24-2007, 17:26:00
They said claim check
Posted By Olena on 04-24-2007, 16:24:00
I just asked our biller and she said that not just Aetna and Cigna
denying 51795. They are saying it's incidental to 51726. My advice would
be to move on, you are not likely to win.
Olena

>>> lflatt@cookevilleobgyn.com 4/24/2007 8:46 AM >>>
We are being denied by Cigna and Aetna on 51795 - they are saying it
is
incidental to other codes; I have lost a 1st level appeal with a
letter
from the American Urological Society which describes each CPT code in
detail. Anyone with success in appealing this or should I just move
on.
The other codes we use are 51726, 51797, 51772, 51784, 51741.

Thanks.


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Posted By Arlene on 04-24-2007, 16:09:00
Have you asked them to provide you, in writing, where they get the information that the codes are bundled. They are not in the CCI edits, so they must tell you where they are getting their bundling information from.>
Posted By Jan on 04-24-2007, 15:54:00
We received a letter from our supplier that said not to use the 51795
anymore based on recommendation from the American Urology Assn. They
stated the leak pressure study was included in the 51772. So we now
bill out 51726 and 51772.
Jan Lasker,
Billing Manager
Oaktree Physicians Inc
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