Technical Denials in Breast Cancer: Breaking the Code

by Gail Robinson, Fotheringill & Wade, LLC Our fifth and final article in honor of Breast Cancer Awareness Month addresses the current trend among commercial payers to limit pre-authorizations to specific Common Procedure Technology (CPT) or Healthcare Common Procedure Code System (HCPCS) codes. This practice has led to an increase in technical denials for no-authorization, when the CPT/HCPCS code billed on a claim varies even slightly from the CPT/HCPCS code authorized. Issue:   With some exceptions (outlined in our prior articles), most surgical procedures and other treatments for breast cancer are covered benefits under standard commercial health plans. However, most covered surgeries and treatments also require prior authorization. If authorization is […]

Strategies to Master IMRT Denials

by Kelley Regan Costello, Fotheringill & Wade, LLC To improve cancer survival rates, the number of providers relying on the use of intensity-modulated radiation therapy (IMRT) to treat breast cancer and other forms of cancers is growing. An unwanted consequence of the increased use of IMRT is an increase in the number of denials for IMRT treatment. Issue: Often authorization requests for IMRT are denied as experimental and investigational because many of the clinical policies insurers rely on to deny IMRT claims are based on outdated clinical sources which do not account for the most recent advances in IMRT. Until insurers policies adequately (and accurately) account for the most recent […]

Legal Mandates for Breast Reconstruction after Mastectomy

by Michael Palisano, Fotheringill & Wade, LLC With Breast Cancer Awareness month upon us, it is important to take account of the various laws that provide for protection and benefits to women who have been diagnosed with breast cancer. While commercial and government insurers are required under law to provide coverage for reconstructive surgery for women who have undergone mastectomy surgery, we still see denials of claims involving breast reconstruction that should rightfully have been covered. Takeaway: In almost any situation, breast reconstruction following a mastectomy should be covered whether your patient is insured by a government or commercial insurer. As long as the claim is coded appropriately to indicate […]

Does 11 Really Mean 12? Breaking Down the Limitations on Mammogram Screening.

by Catherine Caldwell, Fotheringill & Wade, LLC Continuing our series to honor Breast Cancer Awareness Month, in this post we will discuss ongoing denial issues relating to mammogram coverage under Medicare. While each claim is unique, similarities between claims and their denials can provide insight which can be used to prevent future denials. Below we will break down the CMS regulation which provides the parameters for coverage of mammography services for women (42 CFR 410.34(d)) and will present case studies which illustrate interpretation of the policy. Breaking Down the Policy: Mammograms are very important in the early detection and treatment of breast cancer. However, CMS policy places limitations on the […]

Is the threat of Breast Cancer a “Separate Medical Condition” under Tricare’s Breast Implant Removal Policy?

by Elizabeth Emery, Fotheringill & Wade, LLC In honor of Breast Cancer Awareness Month, we would like to start the month off with a brief case study surrounding the diagnosis of breast cancer. The case involved a medical policy that initially denied a claim as a “non-covered” benefit but was approved after an appeal. Although each patient is unique, there are similarities in the patients’ hospital course that help set up a foundation for disputing denials and getting claims paid. This case study focuses on both the uniqueness of the patient as well as the key tools needed to fight any denial.   Case Study Payer:     TriCare Denial Reason:   […]