A review of the records reveals the member to be an adult female with a birth date of 08/26/1985. The member had a diagnosis of pregnancy with leaking of amniotic fluid and suspicion of rupture of fetal membranes (ROM). The member’s treating provider, Deepti Pruthi, MD ordered a ROM Plus testing, which was performed on 03/04/2015. The carrier has denied coverage of the PAMG-1 testing as experimental/ investigational and not medically necessary. There is a letter from the carrier to the member dated 06/22/2015, which states in part: “Placental Alpha Microglobulin-1 (PAMG-1) testing is regarded as experimental and is denied.” There is a letter from the member dated 02/17/2016, which states in part: “As stated by my previous letter … …show more content…
Both PAMG-1 and ROM Plus testing use CPT Code 84112 for billing purposes). Therefore, unless quoted, further references will be made using the name of the actual test performed on the date of service under appeal. Final External Review Decision: The carrier’s decision in denying coverage for the ROM Plus testing [CPT code 84112] that was performed on 03/04/2015 as experimental/investigational was appropriate. The ROM Plus testing [CPT code 84112] that was performed on 03/04/2015 was not medically necessary for the treatment of this member’s condition. Given the fact that standard methods of diagnosis are still the standard of care and widely used and available in all facilities, the expected benefit of the requested ROM Plus test is not more likely to be more beneficial to the claimant than any available standard health care service or treatment. It is not clear if the adverse risks, of the requested health care service, are substantially increased over those of available standard health care services or treatments, because there is not enough data on which to make an assessment of such …show more content…
Omitting this test and performing all standard tests for diagnosis of this condition would not adversely affect the member’s condition or the quality of the medical care rendered. Therefore, the carrier’s decision in denying coverage for the ROM Plus testing [CPT code 84112] that was performed on 03/04/2015 as experimental/investigational, was appropriate. The ROM Plus testing [CPT code 84112] that was performed on 03/04/2015 was not medically necessary for the treatment of this member’s condition. Given the fact that standard methods of diagnosis are still the standard of care and widely used and available in all facilities, the expected benefit of the requested ROM Plus test is not more likely to be more beneficial to the claimant than any available standard health care service or treatment. It is not clear if the adverse risks, of the requested health care service, are substantially increased over those of available standard health care services or treatments, because there is not enough data on which to make an assessment of such risks. The previous denial should be
...health of a patient and a follow up check at the GP’s may be required.
Three examples on why a claim may be denied are: 1. No preauthorization for non-covered benefits, 2. Processing errors on physicians end and/or no sufficient supporting documentation on why a certain procedure was done for a certain diagnosis, and 3. Incorrect CPT or ICD-9 codes. An EOB can prove a certain service or procedure was denied for the reason specified will be included in the “remarks or description field” in the
As a certified medical coder (CCA 11/2012), I have contributed to the HIMS department by helping code inpatient encounters from patients in the Residential Rehab Unit as well as outpatient encounters from the other clinics at this VA applying the official coding conventions outlined in the International Classification of Diseases 9th revision handbook as well as in the VHA’s Official Coding Guidelines, V11.0 dated August 10, 2011. Having coded many encounters over the past 3 years, I can easily determine the main condition after study that is chiefly responsible for a patient’s admission to the hospital. ICD-9-CM defines this as the primary diagnosis code and I find that it is most important to list this code first in your documentation
The adverse risks of the recommended or requested health care service or treatment are not substantially increased over those of available standard health care services or
“NW Bio Announces Two German Approvals: “Hospital Exemption” for Early Access Program with DCVax-L and Eligibility of DCVax-L for Reimbursement.” Northwest Biotherapeutics The future of cancer medicine now. Northwest Biotherapeutics, 10 Mar. 2014. Web. 29 Apr. 2014. .
requiered to determine treatment. Lab tests or imaging is often requiered as well. It’s chronic,
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
With the high degree of variations in health care, patients can be under or over treated or even treated with the wrong treatment for their illness. These unwarranted care techniques can be categorized into three different situations. The first category of unwarranted care is the use of evidence or lack thereof, based on other medical care. The way to explain this category is that a care plan for a patient is proven effective without any proof as to why. The example given by Kongstvedt (2007) is the use of beta blockers post heart attack. Beta blockers prove to be effective in nearly one h...
Reason/Authority/Codes/Characterization: Failed Medical / Physical / Procurement Standards / AR 635-200, Paragraph 5-11 / JFW / RE-3 / Uncharacterized
medical care has been provided and delivered as drastically changed, and this trend is more than
The doctor might also conduct a physical examination to confirm the diagnosis. This is carried out by listening...
Although the harm reduction model seems flawless in principle, all theories follow the same ideal until subjected to practical use.... ... middle of paper ... ... In addition to the amount of hospital days taken by users, the statistics in favor of harm reduction seem irrelevant as these individuals spend the same amount of hospital days per person as several people on average. With such statistical information, it is unsurprising that governments have not fully embraced the harm reduction concept, with some countries reverting back to older methods.
Some of reason that have been suggested that the that United States mortality rates are higher because of higher risk of iatrogenic drugs, drug toxicity, hospital-acquired infections, and that patients have the “do more” attitude but are not explained all the risks (Moses et al., 2013).
Note: This response sheet is for educational purposes only and should not be taken as a clinical diagnosis. Results need to be confirmed by professionals qualified in your state/province.
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.