Insurance review
Description
Collection
Title:
Insurance review
Text:
I received the following notes from a regional insurance carrier that denied
two codes that I had submitted for some additional work done to replace a
knee unit. I ended up having to replace a tube clamp adaptor and aluminum tube
as well as the knee unit because of the height change in the prosthesis
using one model of the knee I was replacing with a newer model. I explained all
of this in my note to the carrier as well as provided a photograph to
illustrate which parts I had to change and the height discrepancy of the two knee
units. Without any other commentary, I'd like to share the reviewer's ( CPO)
notes to the reviewing physician that were sent along with the denial to me.
Please feel free to comment.
I have reviewed the information on this prosthetic service request.
The request for L5950 and L5920 is not reasonable. Only one tube clamp and
a length of 30mm aluminum tubing was changed, not the entire pylon and all
alignable components. The provider will almost certainly use the old tube
clamp in another project, and the tubing was likely in his scrap box. Even if
both of these pieces were purchased specifically for this patient, the cost
for both should be well under $100.00. A compromise might be to ask for a
copy of the invoice for the 4R82 tube clamp and 30mm pylon tube, and pay a
reasonable percentage for handling and the 15 minutes of bench time to change
these items. Asking full payment for these two codes is not justified.
That is the Reviewer's comments. I may note that the tube clamp that was
removed was over five years old, rusted screws that in order to remove had to
be drilled out. The 15 minutes of bench time in reality was approximately
45 actual minutes that were, to say the least 'frustrating'. Unfortunately I
wont be able to use the clamp for other projects darn it.
Your thoughts would be appreciated. Please feel free to critique my coding
choices as well. I am open to any and all comments.
Jerry Nelson CPO
two codes that I had submitted for some additional work done to replace a
knee unit. I ended up having to replace a tube clamp adaptor and aluminum tube
as well as the knee unit because of the height change in the prosthesis
using one model of the knee I was replacing with a newer model. I explained all
of this in my note to the carrier as well as provided a photograph to
illustrate which parts I had to change and the height discrepancy of the two knee
units. Without any other commentary, I'd like to share the reviewer's ( CPO)
notes to the reviewing physician that were sent along with the denial to me.
Please feel free to comment.
I have reviewed the information on this prosthetic service request.
The request for L5950 and L5920 is not reasonable. Only one tube clamp and
a length of 30mm aluminum tubing was changed, not the entire pylon and all
alignable components. The provider will almost certainly use the old tube
clamp in another project, and the tubing was likely in his scrap box. Even if
both of these pieces were purchased specifically for this patient, the cost
for both should be well under $100.00. A compromise might be to ask for a
copy of the invoice for the 4R82 tube clamp and 30mm pylon tube, and pay a
reasonable percentage for handling and the 15 minutes of bench time to change
these items. Asking full payment for these two codes is not justified.
That is the Reviewer's comments. I may note that the tube clamp that was
removed was over five years old, rusted screws that in order to remove had to
be drilled out. The 15 minutes of bench time in reality was approximately
45 actual minutes that were, to say the least 'frustrating'. Unfortunately I
wont be able to use the clamp for other projects darn it.
Your thoughts would be appreciated. Please feel free to critique my coding
choices as well. I am open to any and all comments.
Jerry Nelson CPO
Citation
“Insurance review,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/228661.
