04/15/2019

UHC Community Plan Denials for CPT Code 28899 (1st Denial and 2nd Denial for Appeal)

I just got the answer to my question regarding the 28899 unlisted code and United Health Care Community Plan..the answer was that I should appeal ... Sorry, I should have told you in the original request that I had already appealed this and got another denial .. please advise as to what my next step might be

Unfortunately, the procedure performed does not have a CPT code. The appeal would be the only way to proceed but once the appeal is denied (which is the case in this occurrence) the provider doesn’t have any recourse because the Medicaid HMO does not recognize CPT 28899. Many Medicaid plans follow the state fee schedule on what codes can be paid for a particular specialty. Regrettably, even if an HMO covers more codes than FFS Medicaid, unlisted/unspecified codes are almost never covered. The only way to have this denial overturned is to bill a claim with a more specific CPT code. If one cannot be determined based on the op-reports, the surgery will be a write off since the HMO does not recognize unspecified surgical codes and the patient cannot be billed. It is important to authorize surgical procedures and know what your reimbursement will be, if any prior to engaging in the surgery.