Many times as a coder you will be asked to assist the billing department in correcting a claim that was submitted for medical necessity. Write an appeal to the insurance carrier as why this patient needs the following procedure:
“Your patient needs a blepharoplasty procedure. This procedure is to improve the functioning of a malformed body member. When blepharoplasty procedures (15822–15823) are performed for cosmetic purposes, they are not covered by Medicare. When the function of the eye is impaired by overlying skin or fatty tissue, the repair is deemed medically necessary and should be covered by the insurance company. Explain why your patient is not having this procedure for cosmetic purposes, but for medical reasons.”
Research the MEDICAL NECESSITY GUIDELINES for more information. Write a letter, memo, or use a form-type letter. Double space, spell check and be sure to check for grammar errors, remember this is going to an insurance company – be professional.
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