Good Morning
I am a biller at a plastic surgery practice and I need alittle help with an appeal on an Emergency Room surgery that is being denied as contractual exclusion for a cosmetic procedure that the patient had over 10 years ago. The patient presented to the ER with severe back pain shooting down both legs, ASIA syndrome, and had multiple granulomas all through out her buttocks and thighs. We took her to surgery and started to remove the granulomas. There had to be 2 more surgeries to remove them all and close the wounds. The patient was aware that there would be some deformities after the surgery. This by all means was not a cosmetic procedure and we did not perform the orginal surgery 10 years prior. I have written appeals, so has the patient, we have sent before and after photos and included all medical records. We even had a peer to peer and their doctor agrees about medical necessity but is denying for contractual exclusion. They are stating that they do not cover any problems that arise from a cosmetic procedure no matter how long ago it was. I am stumped. Is there somewhere we can appeal over Aetna?? Any government office we can contact??? Any help would be appreciated!!!!
I am a biller at a plastic surgery practice and I need alittle help with an appeal on an Emergency Room surgery that is being denied as contractual exclusion for a cosmetic procedure that the patient had over 10 years ago. The patient presented to the ER with severe back pain shooting down both legs, ASIA syndrome, and had multiple granulomas all through out her buttocks and thighs. We took her to surgery and started to remove the granulomas. There had to be 2 more surgeries to remove them all and close the wounds. The patient was aware that there would be some deformities after the surgery. This by all means was not a cosmetic procedure and we did not perform the orginal surgery 10 years prior. I have written appeals, so has the patient, we have sent before and after photos and included all medical records. We even had a peer to peer and their doctor agrees about medical necessity but is denying for contractual exclusion. They are stating that they do not cover any problems that arise from a cosmetic procedure no matter how long ago it was. I am stumped. Is there somewhere we can appeal over Aetna?? Any government office we can contact??? Any help would be appreciated!!!!
Thank you for any advice you can give!!