03/23/2021

Obtaining Prior Auth for CPT 97597-Fidelis

I have asked this question before: how to obtain a prior authorization for a procedure 97597. The proper form was submitted but the reply from Fidelis says: the patient does not need prior authorization because he has a Diabetes. The procedure code was denied as "not covered by the Plan".

The ulcer debridement was denied as non-covered by Fidelis because the diagnosis is not justified for a wound debridement according to the insurance. The diagnosis reported would have to be a greater severity (such as a chronic ulcer with the fat layer exposed) in order for the managed care plan to cover the procedure. Regardless of the patient’s diagnosis of diabetes, no authorization is required for the procedure.