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Medical Necessity Denials – ICD-10

Medical necessity denials are expected to increase as a result the ICD-10 code set adoption. The ICD-10 code set is composed of highly-specific codes which may allow payers to apply medical necessity edits with greater accuracy. For example, the acuity level of many chronic diseases will be reflected in the code and allow payers to design medical necessity edits which better match acuity. Further, additional combination codes should facilitate the use of medical necessity edits which allow for easier pass-through of complex-care claims. However, during the implementation phase, medical necessity edits may be a source of incorrect denials and should be reviewed carefully to determine the accuracy of the edits.

Appeal Solutions recommends the following steps for medical necessity denial review under the ICD-10 implementation period:

Request peer review of any medical necessity denial. A clinical peer is defined by the Utilization Review Accreditation Commission (URAC) as a physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review.

Demand and review the carrier’s clinical criteria related to the decision.

Using attachments to make your appeal stronger. Clinical documentation is often crucial to establishing the scope of the treatment, risk(s) considered during treatment plan development and/or the justification for deviations from the standard clinical procedure(s).

If a medical necessity edit does not appear to be correctly applied, your appeal must follow specific payer-specific timeframes and be submitted timely. To assist with medical necessity appeals, review the following sample letters for ICD-10 Medical Necessity Appeals:

ICD-10 Medical Necessity Appeal – Request for Peer Conversation

ICD-10 Medical Necessity Appeal – Demand for medical necessity edit transparency

ICD-10 Medical Necessity Appeal – Response to overly broad/repeat request for records

Sample Medical Necessity Appeal Letter - ICD-10

Request for Peer Conversation

[~Current Date~]

Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Date: [~Treatment Date~]

Amount: [~Amount~]

Dear Provider Appeals,

According to our records, your company has rendered an adverse determination related to the medical necessity of the above referenced treatment. It appears the denial may involve newly developed ICD-10 medical necessity coding edits.

We request that the medical professional who made the adverse determination contact the attending treatment provider immediately to discuss this clinical decision. As you are likely aware, peer-to-peer conversation regarding treatment provides an opportunity for the face-to-face treating medical professional to discuss the course of treatment and the patient's unique clinical variables. A clinical peer is defined by the Utilization Review Accreditation Commission (URAC) as a physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review. Generally as a peer in a similar specialty, the individual must be in the same profession, i.e., the same licensure category as the ordering provider.

If peer-to-peer discussion is not provided as requested, please provide the following information, which should have been properly disclosed with the initial denial:

Name of the board certified reviewer who reviewed this claim and a description of any applicable advanced training or experience this reviewer has related to this type of care;

Board certified reviewer’s recommendation regarding alternative care;

A copy of applicable ICD-10 medical necessity clinical guidelines applied, the date of development and method of notification;

An outline of the specific records reviewed and a description of any records which would be necessary in order to justify coverage of this treatment;

Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company in regard to treatment of this nature and its efficacy

It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.

Thank you for your assistance.

Closing Text,

Additional Customization Suggestions:

Attach Medical Records

Cite Internal Clinical Criteria used to develop Treatment Plan

Cite Managed Care Medical Necessity Review Requirements

Sample Medical Necessity Appeal Letter

Demand for Medical Necessity Edit Transparency

[~Current Date~]

Attn: Provider Appeals

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Date: [~Treatment Date~]

Amount: [~Amount~]

Dear Provider Appeals,

According to our records, your company has rendered an adverse determination related to the medical necessity of the above referenced treatment. It appears the denial may involve newly developed ICD-10 medical necessity coding edits.

It is our position that ICD-10 medical necessity coding edits must comply with published industry standards and be consistently applied across all claims. It does not appear that this medical necessity edit has been supported by evidence-based medicine or any payer guidance citing clinical support for this edit. Therefore, please provide the following information so that we may determine the accuracy of this decision:

A copy of applicable ICD-10 medical necessity clinical guidelines applied, the date of development and method of notification;

An outline of the specific records reviewed and a description of any records which would be necessary in order to justify coverage of this treatment;

Copies of any peer-reviewed literature, technical assessments or expert medical opinions reviewed by your company in regard to treatment of this nature and its efficacy;

It is our position that failure to provide the requested information may violate state and/or federal claim processing disclosure laws or, in the minimum, non disclosure reflects a poor quality medical process which discourages treatment provider input. Disclosure standards are meant to ensure that all qualified parties have access to the information necessary to properly appeal an adverse determination. Therefore, we appreciate your prompt, detailed response to this request.

Thank you for your assistance.

Closing Text,

Additional Customization Suggestions:

Attach Medical Records

Cite Internal Clinical Criteria used to develop Treatment Plan

Cite Managed Care Medical Necessity Review Requirements

Sample Medical Necessity Appeal Letter 3

Response to Overly Broad ICD-10 related Clinical Documentation Requests

[~Current Date~]

Attn: Director of Claims

[~Insurance Policy #1 Address~]

Re: Patient: [~Patient Name~]

Policy: [~Insurance Policy #1 Number~]

Insured: [~Responsible Party Name~]

Treatment Dates: [~Admission Date~] - [~Discharge Date~]

Amount: [~Total Charges~]

Dear Provider Appeals/Compliance Officer,

According to our records, your company is has requested clinical documentation related to the above requested care. Further, it appears documentation is necessary to establish the accuracy of recently-implemented ICD-10 codes.

The Utilization Review Accreditation Commission (URAC) standards are widely recognized guidelines for medical review and clinical documentation requests. One of these standards protects medical providers from the burden of overly broad requests for unnecessary medical documentation.

Please review your request for compliance with Standards UM 26 which states:

The organization, when conducting routine prospective review, concurrent review, or retrospective review:

(a) Accepts information from any reasonable reliable source that will assist in the certification process;

(b) Collects only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services

(c) Does not routinely require hospitals, physicians, and other providers to numerically code diagnoses or procedures to be considered for certification, but may request such codes, if available;

(d) Does not routinely request copies of all medical records on all patients reviewed;

(e) Requires only the section(s) of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work; and

(f) Administers a process to share all clinical and demographic information on individual patients among its various clinical and administrative departments that have a need to know, to avoid duplicate requests for information from enrollees or providers.

It appears that your request may be more expansive than is necessary to document the ICD-10 code selection for this claim. Therefore, we request that a complete explanation be provided for the need for additional records or that the specific item(s) from the medical records be identified so that those records alone can be submitted for review. Thank you for your assistance in this matter.

Closing Text,

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