Tammy Posted Wed 22nd of April, 2015 16:54:10 PM
We are having an on-going issue that I hope you and other readers can help with. When doing an EGD with botox injection for gastroparesis our local hospital insists that we pre-auth the procedure. Many times this is being done on a MCARE or MCAID patient, and they won't pre-auth as this isn't required. Even if I do a pre-auth (for other payors)I would only obtain the auth for 43236 (EGD with injection), and again, most insurance companies will tell us a pre-auth is not required. We are not supplying the botox--the hospital is. They apparently aren't getting paid for the botox. I realize some insurance companies view this as investigational. How do you recommend handling this? Should the hospital obtain a pre-auth for the botox?
SuperCoder Answered Thu 23rd of April, 2015 06:54:59 AM
Major payers including United Healthcare and Aetna, they do not cover the botox injection for any kind of gastroparesis including diabetic gastroparesis. They provide several researches to support it. Therefore, I think the claim would be denied if you will bill it without a preauthorisation, although it is not sure whether they will either provide the coverage at all.