Susan Posted Mon 12th of August, 2019 12:06:18 PM
This patient has Barretts Esophagitis k22.70 and had an EGD with Ablation 43270. BCBS of Georgia has denied due to "not covered" when deemed experimental/unproven. What documentation can I use for an appeal to fight the denial?
SuperCoder Answered Tue 13th of August, 2019 10:14:55 AM
Thanks for your question.
Firstly, the documentation should be thoroughly reviewed, and whether the code 43270 is applicable to the medical documentation and medical necessity is established for the procedure.
Secondly, the denial states ‘not covered’ when deemed experimental/unproven, this may suggest that there is insufficient or inconclusive medical and scientific evidence to permit the Plan to evaluate the therapeutic value of the service, or procedure.
We also request you to kindly share the EOB (explanation of benefit), so that we can have a look at the reason for denial and provide you with the documentation.
Please share the EOB on firstname.lastname@example.org.