03/27/2020

Part 2: Fidelis Not Paying 97597 or 29740

Can you please tell me what we need to do to fight these insurance companies? 1. Humana is not recognizing the SX modifier for 11720/1 with 11055/6/7 anymore. Bundling and denying the 1105- or the 1172- code. 2. Fidelis- not paying the 97597 debridement code or the 29740 strapping code as of sometime middle of last year. 3. BCBS is not recognizing the SX modifier for 11720/1 with 11055/6/7 anymore. They will not pay the paring of lesions with the debridement anymore. With Humana you can appeal with notes and I think they finally pay. But shouldn't these companies be going by Medicare guidelines? And how can they just stop paying for something they always paid for without any notice?

With Fidelis, CPT codes 97597 & 29540 are not on the NYS Medicaid fee schedule. Managed care plans are allowed to cover services that are not on the state fee schedule, but at the bare minimum must cover what FFS Medicaid covers. A plan has the ability to amend what procedures it covers- if they are denied as non-covered, the only recourse that can be done is to submit an appeal to request for the procedures to be considered on the basis of medical necessity.