Category Archives: Breast Cancer Awareness

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 not obtained for the exact services rendered, increasingly identified by CPT/HCPCS code, payment may be denied for no-authorization.

Takeaway: Be aware of payer timeframes to revise an authorization, which can vary from two days to two weeks, post-service. If the exact procedure code cannot be determined in advance, establish procedures to request a range, or alternative codes. Keep records of these requests. Use these records to establish that the payer’s protocols were followed; therefore, a post-service clinical review for medical necessity of the procedure (code) performed is required on appeal.


Healthcare providers utilize CPT/HCPCS codes to report services performed on patients. Some procedure codes are very specific. Others are more general with the potential for overlap or confusion “[b]ecause many procedures can be performed by different approaches, different methods, or in combination with other procedures, there are often multiple HCPCS/CPT codes defining similar or related procedures.”[1]

Commercial payers are progressively linking prior authorizations to specific CPT/HCPCS codes. This is problematic in cases where a particular surgery or treatment is anticipated, but a slightly different procedure is performed. A physician may use his or her best professional judgment in planning, but the claim is coded based on the medical record after-the-fact, when any slight clinical variance can cause a different code to be billed. Payer timeframes for requesting revision of a prior authorization can vary from two days to two weeks, post-service. Unfortunately, it can take that long for the medical record to be finalized, the claim coded, and the variance identified.

Case Study 1:  A payer issued an authorization for HCPCS code J9355 for the chemotherapy agent Trastuzumab (brand name: Herceptin) for a 45 year-old woman with HER2 positive breast cancer. The patient was given J9354, Trastuzumab-Emtansine (brand name: Kadcyla) and the claim denied for no-authorization. The provider could not locate the authorization request to prove that the wrong drug had been authorized.

To state the obvious, J9355 and J9354 which are 1 digit apart, and the generic names “Traxtuzumab” and “Trastuzumab-Emtansine,” can be easily confused. Despite the lack of an authorization request, Fotheringill & Wade successfully demonstrated the high likelihood of confusion by citing a 2013 Safety Alert published by the FDA[2] which cited potential medication errors due to the similarity in name, and mandating the use of the prefix “Ado” before “Trastuzumab-Emtansine” for Kadcyla, to distinguish it from Herceptin.

Case Study 2:  Consider the case of a 36 year-old woman who presented for a right-sided symmetry reduction after a left-sided mastectomy and reconstruction. For the symmetry procedure, the provider obtained prior authorization for CPT code 19318 “reduction mammaplasty,” which includes removal of excess breast tissue. Unfortunately, the provider billed CPT code 19316 “mastopexy,” which is a skin reduction breast lift, with removal of underlying breast muscle. The difference was an unanticipated and very slight reduction of muscle to reorient the breast, as identified in the operative report. The timeframe for revising the authorization had passed, and the claim denied for no authorization.

To again state the obvious, 19316 and 19318, as well as “mammaplasty” and “mastopexy,” could be easily transposed. Both codes describe breast reduction and involve removal of excess tissue; mastopexy is only more specific in that it addresses removal of muscle.

Confused? Maybe the payer was too, and authorized a different code than you requested. Check your authorization request, the authorization granted, and your coding of the claim. Evidence that you requested authorization for the service performed is a strong indicator of payer error. Even if you performed a service that is different than the authorization requested, similarities of codes can be effectively argued.

One of the most important elements in disputing a technical denial is evidence that the payer’s authorization protocols were met. In this case, prior authorization was properly requested and granted, but for a slightly different code. Prior authorization is the payer’s confirmation that a procedure is approved as medically necessary, and it would follow that a slight variance was medically necessary too. A clinical comparison of the similarities in the procedures may be your best administrative argument.

Finally, address the unpredictability of the variance. A clinician using their best professional judgment may know what services are necessary but cannot predict how the claim will be coded. From a clinical standpoint, explain why the procedure performed was unanticipated but medically necessary as opposed to the procedure that was authorized. If possible, explain why a different code was used on the claim.


Technical denials for no-authorization are not limited to breast cancer treatments, and the strategies discussed herein can be used for any denial when a different CPT code than is authorized is performed. We expect that these technical denials will continue to increase as payers progressively define service authorizations more narrowly.


[1] National Correct Coding initiative Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (01/01/2014)

[2] U.S. Food and Drug Administration, “Kadcyla (ado-trastuzumab emtansine): Drug Safety Communication – Potential Medication Errors Resulting from Name Confusion” (05/06/2013) at

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 clinical advances, providers will continue to face denials for the use of IMRT in the treatment of breast cancer.

Takeaway: IMRT denials often based on policies which reflect outdated clinical sources. When faced with denials for IMRT, specific clinical facts and documentation that support the service provided, combined with current clinical studies which document the recent advances and benefits of IMRT, can form a strong argument for an overturn of the denial.


To help facilitate and ensure the providers successfully overturn denials upon appeal, please consider the case study below and the means by which a provider can overturn similar denials despite an insurer’s outdated policy.


Denial Reason: Commercial insurance payer denied provider’s request for authorization for IMRT treatments as “experimental and investigational.”

Case Facts: 30 year old woman diagnosed with breast cancer after an ultrasound showed a 2.7 cm irregular mass in the left axilla, with abnormal appearing enlarged lymph nodes. Fine needle aspiration showed adenocarcinoma with metastatic adenocarcinoma in the lymph nodes. Patient underwent a partial mastectomy. A needle biopsy was positive. Patient underwent chemotherapy and subsequently, presented for five (5) IMRT treatments, which was a successful approach for this patient.

Appeal Strategies:

I.  Use the outdated clinical policy information to your advantage.

Under this patient’s specific health plan, the insurer’s IMRT policy is based on studies conducted in 1999 and 2002, a veritable lifetime ago when measured in the lifecycle of medical technologies. The cited studies claim that it is not clear if the improvements achievable with IMRT will lead to significant clinical outcome improvements and further that IMRT offers no clinical advantage over standard therapy. While this may have been true when the studies were conducted, recent studies will show that this is no longer the case.

Recent research shows that IMRT is almost universally accepted as being superior in reducing the side effects of radiation, such as reducing heart diseases, reducing recurrence rates and second malignancies. Use this updated and accurate clinical information to refute the denial contention that IMRT is experimental and investigational. Let the clinical research argue for you to show that the IMRT outcomes are better because higher doses can be delivered in the tumor, targeting volume while reducing dose to critical organs in the surrounding areas.

II.  Approach each appeal on a case-by-case basis.

Each case is unique and a thorough review of the medical records is required to identify the necessary clinical facts, such as patient’s history and treatment, that support the service provided. In our case study, because of the patient’s positive axillary lymph nodes, the proposed method of treatment was irradiation of the breast/chest wall and regional lymph nodes. An appeal could argue that it is considered reasonable and medically necessary to spare the surrounding normal tissue (i.e. cardiac and pericardial structures, lung, spine, and other vital components of the body), a recognized objective of IMRT. This patient required CT guidance for placement of the radiation therapy fields to determine the normal tissues around the treatment area that needed to be blocked from irradiation. Through IMRT, a more accurate volume of the treatment field can be determined in higher doses for the patient, to decrease radiation delivery, which is yet another reason to support IMRT for this patient.

III.  Evaluate the success of the treatment.

Was receiving IMRT treatment critical to this patient’s survival? Did it work? Providers are seeing overwhelming amount of success with these IMRT cases every day. If IMRT treatment was successful, highlight the success of the treatment in your appeal.


Modern medicine has shifted in the direction of IMRT as a means for treating breast cancer. Clinical research and studies have become more prominent proponents on this treatment of this proven benefit. Providers should not be denied reimbursement simply because insurance companies are slow to adopt the new, effective technology, especially since it’s suited for treating these patients in order to yield better and more positive results. Ultimately, an IMRT denial should not discourage providers. Appealing in these cases is the right thing, you can win the IMRT denial appeals and continue rendering successful and reliable treatment while using the “state-of-the-art” radiation while generating revenue in these cases.

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 that the patient has breast cancer and medical records can be submitted to show the circumstances of the surgery, there should be no reason that a hospital should not receive full reimbursement for breast reconstruction. It is important to coordinate with your scheduling department to make sure that, if necessary, prior authorization is obtained, although it should be a formality to determine that it is not a cosmetic surgery and is being done on a patient who qualifies for the surgery.

Issue: Although breast reconstruction is a covered benefit under any understanding of the law, there can be roadblocks to reimbursement. Medicare and Medicare advantage plans may subject coverage of breast reconstruction following mastectomy to certain local and national coverage determinations. Commercial and government insurers alike may still require prior authorization or notification for the procedure. There can often be confusion on this point, as many commercial insurers may not require notification or authorization.


In 1998, Congress passed the Women’s Health and Cancer Rights Act. This act amended the Employee Retirement Income Security Act of 1974 (ERISA) to provide mandatory coverage for breast reconstruction for patients that are insured through self-funded group health insurance plans which are governed by ERISA.[1] The language of the law itself is quite broad. Section A states that the health plan “shall” provide coverage, meaning that it is an affirmative duty of the health plan to provide the coverage. The coverage that is mandated must cover “all stages of the reconstruction of the breast on which the mastectomy has been performed,” surgery and reconstruction of the non-affected breast in order to “produce a symmetrical appearance” and prostheses and all potential complications of mastectomy. In addition, section B requires the plan to provide written notice of the availability of this coverage to its members in its yearly notice of coverage.

State laws also provide for similar coverage for members who are insured through fully funded group health insurance plans. In Maryland, nearly identical language exists to provide coverage for these services as in the federal law; section c of §15-815 states that health insurers must provide coverage for all stages of reconstruction of the breast on which the mastectomy has been performed as well as surgery necessary to preserve symmetry on the non-affected breasts as well as any complications of mastectomy. The Code of Maryland Regulations (COMAR) also requires breast reconstruction to be covered after mastectomy as part of the standard comprehensive benefits offered group health plans licensed to operate in the state.[2]

In Maryland, it can also be argued that Medicaid MCOs are required to provide coverage for reconstruction following mastectomy, although the language in the regulation which governs this is not specifically worded to apply solely to breast cancer. COMAR states that an MCO must provide medically necessary surgery to correct deformities that have been caused as the result of disease. Fotheringill & Wade has been able to argue successfully that this provision requires an MCO to provide restorative plastic surgery following a mastectomy. C.L. was a 45 year old enrollee with a Maryland MCO. Her claim was originally denied after she had breast reconstruction after a mastectomy because it was originally considered to be a purely cosmetic procedure. After appealing the claim, Fotheringill & Wade was able to convince the MCO to reprocess and pay the claim after discussions with attorneys from the MCO in which we cited the specific COMAR provision described above which mandates restorative plastic surgery.

The Maryland Insurance Commission has previously penalized commercial insurers for denying breast reconstruction claims for lack of notification when the patient’s certificate of coverage stated that no notification was required. The original denial was maintained even after the provider had appealed and was only resolved when the provider sought the involvement of the Maryland Insurance Administration, who brought the matter before the Maryland Insurance Commission. As a result, the insurer was fined $500.00 for failure to pay a claim without just cause.[3] Patient cooperation can be key to fighting any sort of denials that a provider might encounter, so it is worthwhile to coordinate with patients who are undergoing breast reconstruction to make sure that they are informed as to their rights under the law.

[1] 29 USCA §1185(b)


[3] Insurance Commissioner v. UnitedHealthcare Insurance Company, Case No. MIA-2010-03-038 (March 16, 2010), http://

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 circumstance under which Medicare will provide coverage for mammography screening. 42 CFR 410.34(d) states the following:

  •  “The service must be, at a minimum a two-view exposure (that is, a cranio-caudal and a medial lateral oblique view) of each breast.
  •  Payment may not be made for screening mammography performed on a woman under age 35.
  • Payment may be made for only 1 screening mammography performed on a woman over age 34, but under age 40.
  • For an asymptomatic woman over 39 years of age, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.”[1]

(DISCLAIMER: the regulations do allow for diagnostic mammograms. If a patient presents with symptoms that would warrant the need for a mammogram, the provider is allowed to perform a mammogram outside of the above mentioned situations. The regulations relating to be requirement for diagnostic mammograms can be found in 42 CFR 410.34 (b). Additionally, diagnostic mammograms are available for men who are covered by Medicare.)[2]

 The Limitations

 Subsection 2

This subsection states a concrete rule. NO PAYMENT will be made for mammograms if the patient is under 35 years old. This should be an automatic red flag for all providers. Unless the patient has additional coverage through another insurer (Medicaid or Commercial), there will be no payment made by an insurer.

Subsection 3

This subsection indicates that payment MAY be issued for a mammogram performed on a patient who is over the age of 34 but younger than 40. Please note, this does not allow for an annual mammogram for patients in this age range. The regulation states that only ONE mammogram may be covered for women in this age bracket. As such, if you have a patient that falls within this qualification, it is extremely important to ask the patient if she has ever had another mammogram. Not asking this question runs a risk of an automatic denial.

Subsection 4

This subsection appears to cause the most issues for providers. At the first reading the subsection does not seem very complex. So then why do we see so many denials under this subsection? The issue becomes clearer if you look closely to the wording. What exactly does 11 months after the month from the last mammography mean? How does the claims processor count the months? A few case studies shed some light on how exactly the subsection is used to deny cases.


Case Studies

Study #1:

Denial Reason: Patient’s mammogram benefits for the year had been exhausted.

Case Facts: 79 years old woman covered by Medicare was seen for a mammogram on 6/30/14. The patient’s last mammogram screening was performed on 7/1/13.

Discussion: For those of you counting at home, 11 months from July 1 is typically June 1 of the next year. So, why was this claim denied? The denial comes down to the exact wording of the regulation. The regulation specifically states that coverage may be given for a mammogram performed after at least 11 months have passed following the month in which the last screening mammography was performed. The regulation is being interpreted as to require that the patient wait 11 months after the month in which they had their previous mammogram. In this case, the provider would have needed to count from 8/1/13 (the first of the month after the month in which the patient had her previous mammogram) making the patient’s mammogram due 7/1/4, just one day after the patient had her mammogram.

 Study #2:

Denial Reason: Patient’s mammogram benefits for the year had been exhausted.

Case Facts: 59 years old woman came to her provider for her annual mammogram on 07/01/14. The patient’s last mammogram screening was performed on 8/15/13.

Discussion: This case is a little easier to determine why the claim was denied. From date to date, there is only a 10 month gap between the mammograms. However, using the terminology of the regulation, the provider would have needed to count 11 months from 9/1/13. The mammogram was provided prior to expiration of the timeframe under the regulation.



Though the provider is still fighting the denials on both of the above claims, these denials show that the timing for mammograms is key to safeguard the likelihood of payment. Providers should check their records to confirm when a patient had her last mammogram. If this is the patient’s first mammography visit to your office/hospital, it is imperative that the provider question the patient as to when her last mammogram was performed. Providers are also better served to err on the side of caution and calculate the 11 months starting the first day of the month after the previous mammogram. Although there is no guarantee of payment, taking steps to ensure that the claim is compliant with all of the applicable regulations can assist in faster payment.


[1] 42 CFR § 410.34(d) (1998).

[2] Id. Sub. Section (b).

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:    Claim denied as a non-covered benefit
Question:    Can the services be covered under the medical policy?

Case facts:    48-year old woman with a family history of breast cancer presented to her primary care physician with complaints of lumps in her left breast. After x-rays and other diagnostic exams, her primary care physician concluded that a biopsy was required. The patient had breast implants and the lumps seemed to be growing next to the silicone implant. Tests indicated that some of the lumps were behind the implant. The physician determined that the biopsy could not be completed without removing the left silicone implant and that the implant could not be put back in after the biopsy was complete. Since the removal of one implant would disfigure the patient, the physician ordered both implants be removed.


At first glance, a clinical policy might seem stringent and inflexible. Upon closer examination, we often find that the terminology in the policy can work in the provider’s interest to get a claim covered. For the denied claim in our case study we used a thorough review of the policy to successfully fight the “non-covered” denial.

Tricare Policy states that removal of silicone or saline breast implants will only be covered if:

the initial… implantation was or would have been a covered benefit; or if the initial implant was not covered, the removal may be covered only if it is necessary treatment of a complication which represents a separate medical condition.  (Emphasis added)

In this case, the initial implantation was not covered, nor would it have been. The patient had the implants for purely cosmetic purposes and it was not a covered service. However, the medical records clearly set out information as to why the removal was necessary and through appeal, we demonstrated that the biopsy constituted a separate medical condition for which the removal should be covered.

Breaking Down the Policy:


The term “may” indicates that the insurer has agreed to review the documentation you submit in support of the care you have given or plan to provide. This is a powerful tool when your documentation and medical records clearly set out the reasons for the service.

“Necessary Treatment”

The term necessary is subjective and ambiguous. Even if we could push an insurer to give a definition that is more precise, it all comes down to reviewing the medical records and determining whether the service was required. We view this as a good thing. It allows the skilled appeal writer to dig into the details of the case and pull out the facts that demonstrate the necessity of a service. Highlighting the details for the insurance reviewer ensures that the services are viewed in the best possible light.

In our case study, it was necessary to remove the implant for several reasons, including the fact that the implant can interfere with the diagnosis of breast cancer. Further, if a puncture were to occur during the biopsy, it may not be identified immediately and the patient would have to be readmitted at a later date for removal/repair.

“Complication which represents a separate medical condition”

The Tricare policy points out that complications do not include damage to the implant: “hardening, leakage… are considered unfortunate sequelae from the initial non-covered surgery” . But the policy is silent as to what may be constitute a separate medical condition. This definition is, therefore, extremely broad. It gives the provider an opportunity to explain the individual’s clinical condition and to argue that the services should be considered a separate medical condition.

In our case study, potentially malignant tumors located around the breast implant constitute a separate medical condition. The tumors are not a result of the patient’s decision to have breast implants in the first place and, as explained above, it was necessary to remove them in order to properly diagnose the patient.


Whether your appeal team is in-house or an outside firm, the medical records and documentation can prove that a service falls under the policy even when the claim denied as non-covered. Don’t accept the denial without pushing back. Close examination of the clinical policy can prove that the services rendered are covered and should be paid.


[1] Tricare Policy Manual 6010.57-M, Ch 4, Sec. 5.5 Sub. Sec. 3.1, 3.3

[2] Id. at Sub. Sec. 4.2