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Procedure code 62287. Predetermination denied

Been dealing with a "protruding disc with a tear" since 2011. Diagnosis code 722.10. Had all the epidurals, radio frequency, etc. It has gotten progressively worse and now the treatments do no good at all. UMR has denied my pre-determination for the minimally invasive discectomy (62287), calling it "investigational or experimental, based on current medical literature". The pre-determination can't be appealed. So they want me to pre-pay the Doc the $5000 if I want the surgery and then file, and more than likely appeal.

Has anyone experienced this sort of thing? I feel like if I had the right "medical literature", then I could approach my HR people and get them to over ride this determination. My company is self-insured, UMR only handles the claims. I did find one instance where a physician sued BCBS and won on this very procedure.
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Comments

  • dilaurodilauro ConnecticutPosts: 13,279
    We have still not reached a 100% standard in those.

    I am not sure, but from your post, it appears that you want to go ahead with a procedure. What I am not sure of, because protruding disc, tear is such a common general term.

    I am not sure where you are located, but normally in the states, if a Doctor feels that a patient requires a specific surgery, they will be the ones making sure all the paper work, coding, etc is done. When a patient requires a procedure, doctors are not going to be stopped because of an insurance coding situation
    Ron DiLauro Veritas-Health Forums Manager
    I am not a medical professional. I comment on personal experiences 
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