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.
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.
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.
 Tricare Policy Manual 6010.57-M, Ch 4, Sec. 5.5 Sub. Sec. 3.1, 3.3
 Id. at Sub. Sec. 4.2