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Acupuncture The guidelines note that the amount of acupuncture to produce functional Improvement
is 3 to 6 treatments....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Acute Rehab, Inpatient Physical/Occupational Therapy MTUS page 42 states that
Detoxification is defined as withdrawing a person from a specific psychoactive substance and it does not
imply a diagnosis of addiction, abuse or misuse....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Aquatic Therapy Chronic Pain Treatment Guidelines state that aquatic therapy (up to 10 sessions) is
recommended as an optional form of exercise therapy where available as an alternative to land-based
physical therapy. They go on to state that it is specifically recommended whenever reduced weight
bearing is desirable, for example extreme obesity....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Arthroscopic decompression (acromioplasty) (shoulder)
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Arthroscopy rotator cuff repair MTUS/ACOEM Guidelines state that rotator cuff repair is
indicated for significant tears that impair activities by causing weakness of arm elevation or rotation,
particularly acutely in younger workers.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Autonomic Nervous System Evaluation: Per the ODG, autonomic nervous system evaluation is
not generally recommended as a diagnostic test for CRPS. The ODG recommends assessment of clinical
findings as the most useful method of establishing the  diagnosis....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Bilateral lumbar facet neurotomy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Biofeedback According to the MTUS treatment guidelines for  biofeedback it is not Recommended as a
stand -alone treatment but is recommended as an Option within a cognitive behavioral therapy program to
facilitate exercise Therapy and returned to activity.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Bone growth simulator The Official Disability Guidelines indicate that bone growth stimulators are
under study and may be considered medically necessary as an adjunct to lumbar spinal  fusion surgery for
patients with any of the following risk factors for failed fusion: ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Botox injection Criteria for a botulinum  toxin (Botox) for prevention of chronic migraine headaches
include a diagnosis of chronic migraine headache  with  frequent headaches lasting  4 hours a day or  
longer,  And not responsive to at least three prior first -line migraine headache prophylaxis medications.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Carpal Tunnel Release Official Disability Guidelines were also referenced for more specific
recommendations. According to the Official Disability Guidelines regarding surgery for carpal tunnel
syndrome, Recommended after An accurate diagnosis of  moderate or severe  Surgery is not generally
initially indicated  for mild CTS unless symptoms persist after conservative treatment.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Chiropractic care According to Chronic Pain Medical Treatment Guidelines, MTUS (Effective July
18, 2009) Page 58, Manual therapy & manipulation: Recommended for chronic pain if caused by
musculoskeletal conditions. Manual Therapy is widely used in the treatment of musculoskeletal pain....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Cognitive behavioral therapy ODG Cognitive Behavioral Therapy (CBT) guidelines for chronic
pain recommend screening for patients with risk factors for delayed recovery, including fear avoidance
beliefs.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Complete Blood Count Complete Blood Count . Per the cited guidelines The presence of
infection is defined by 2 classic findings of inflammation (redness, warmth, swelling, tenderness or pain)
or purulence.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation to Psychologist According to the MTUS psychological evaluations are generally
accepted, well-established diagnostic procedures not only with selective use in pain problems,....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation with Neurology "The occupational health practitioner may refer to other specialists
if a diagnosis is .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Consultation with Pain Management Specialist "The occupational health practitioner may
refer to other specialists if ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Continuous-flow Cryotherapy MTUS/ACOEM  is silent on the issue of cryotherapy.
According to ODG, .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

CT scan Per ODG guidelines,.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic facet blocks The ODG notes: Criteria for  the use ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Diagnostic nerve blocks....MTUS is silent on selective nerve root blocks. Under ODG, ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

DVT Prophylaxis unit...
•         Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Elbow ulnar nerve decompression and medial epidonylectomy CA MTUS/ACOEM is
silent on the issue of surgery for cubital tunnel syndrome. According to the ODG, ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Electronic psych testing          The Industrial Guidelines do not specifically address
Electronic psych testing: but does  address ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

EMG .Decision rationale: Electromyography (EMG) is a diagnostic test used to measure
....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

EMG/NCV (Electromyogram/Nerve Conductive Velocity) ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

EMGs (electromyography)...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Epidural Injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Extracorporeal shock wave therapy The official disability guidelines recommends extracorporal
shock wave therapy for certain conditions ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

FRP Multidisciplinary evaluation to assess candidacy for FRP....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Functional Capacity Evaluation ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Functional RESTORATION AFTERCARE PROGRAM...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

H Wave ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hand/Wrist Home Exercise Rehab Kit....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hernia repair....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Home health aide....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

•        Home health physical therapy ODG Guidelines consider home health services as medically
necessary When .....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues....

Hypnotherapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Implantable Drug-Delivery Systems ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Inpatient detox....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Inpatient Detoxification Program Detoxification is defined as .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Interdisciplinary pain programs.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Interferential (IF) unit Interferential current works in a similar fashion as TENS, but at a
substantially higher frequency (4000-4200 Hz....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Knee arthroscopy with meniscectomy “......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Knee brace Official Disability Guidelines' criteria for custom fabricated k...
       Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Life Skills and cognitive coach The California MTUS, ACOEM, and ODG all do not reference a
life skills.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

LINT (Localized intense neurostimulation therapy)....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

LSO Brace " ODG Guidelines regarding lumbar supports states "not recommended for
prevention, however, .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Lumbar spinal fusion....
•        Criteria: (ODG),....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Manipulation under anesthesia....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medial Branch Block ODG as cited below: "Criteria for the use ....medial branch blocks; ODG
recommends ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medication Management ODG cites that "....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Medication Management / Pharmacological Management
•        Criteria: ODG states .....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues....

Metal artifact reduction ....     
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Knee and Leg...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

ODG states that a brain MRI is recommended for the following indications:...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Headaches:....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Elbow....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Forearm,....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Wrist and Hand.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Neck and Upper Back.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI of the abdomen,....
       Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

•        MRI Pelvic / Hip.....
o        Criteria (Clinical  documentation)....
o        Common Errors:...
o        Billing Codes and Payment Issues..
..

MRI Shoulder Injury The criteria for MRI of the shoulder include....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRI Spine / Low Back ODG guidelines Low Back Chapter MRI Topic, state... ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

MRIs (magnetic resonance imaging)....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Nerve Conduction Studies....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Nerve Conduction Velocity (NCV).....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Chapter, Proton Pump Inhibitors (PPIs)......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Occupational therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

ODG (Compounds General) Topical analgesics.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Open reduction and internal fixation of left.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Fibula under fluoroscopy a rod, plate and/or nails) is then ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

OPIOIDS ON -GOING MANAGEMENT....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Orthovisc injections .ODG Guidelines,.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Hyaluronic acid injections is Recommended.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Outpatient Detox
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Management Consult.......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Psychology Evaluation.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pain Pump....
       Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Patient education classes.....

•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pens Therapy  Percutaneous electrical nerve stimulation ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Physical therapy....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

Physical therapy with massage.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op lab work ODG used.As per cited guidelines for Preoperative lab testing,......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op medical clearance......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-op studies chest x-ray.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pre-Operative EKG.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Proton pump inhibitor....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Proton Therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

PRP (platelet rich plasma) injection     
•               Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psych Evaluation to determine candidacy for entry and participation into the Functional
Restoration Program......
       Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psyche testing SC-90-R.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychiatric Evaluation......
       Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychological Treatment incorporated.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Psychology referral.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Pulmonary Function Test......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

ODG notes recommendations for Spirometric testing in the workplace where spirometry is
employed in the primary, secondary, and tertiary prevention ....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Range of motion test ODG states regarding Range of Motion, "Not recommended as primary
criteria, ...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Referral to a nutritionist....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Rotator cuff repair .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Sacroiliac joint injection Guidelines recommend sacroiliac blocks as an option.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Spinal cord stimulation General Criteria for a spinal cord stimulator trial....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

Static progressive stretch (SPS) therapy.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

TENS unit transcutaneous electrical nerve stimulation Criteria:......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

TFESI under Fluoroscope....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Transportation.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Trigger point injections.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

U/S Guided Corticosteroid Injection......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Unna boot.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Urine toxicology.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

.Video Fluoroscopic Evaluation of the Shoulders (with motion).....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Viscosupplementation injections.....
•         Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Voltage-Actuated Sensory Nerve Conduction Threshold of Lumbar Spine...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Weight loss program...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work conditioning...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work Conditioning Program physical therapy....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work Harding Screening "......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

X-Rays Guidelines state.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

Yoga Sessions .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Drug Class        Generic Name        Brand Name

Antidepressants        Amitriptyline        Elavil® Recommended. Amitriptyline
is a tricyclic antidepressant. Tricyclics are generally considered a first-line agent unless
they are ineffective, poorly tolerated, or contraindicated.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Bupropion        Wellbutrin®
a second –generation non –tricyclic anti-depressant (a nor-adrenaline and dopamine re-
uptake inhibitor) has been shown to be effective in  relieving neuropathic pain of different
etiologies in a small  trial
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Citalopram        Celexa
Celexa (citalopram)is a selective serotonin reuptake inhibitor (SSRI) and is FDA
approved for the treatment of depression. Its role in chronic pain is less clear.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Duloxetine        Cymbalta®
Citalopram is a selective serotonin reuptake inhibitor that belongs to a class of
antidepressants. It has been suggested that its role is in addressing psychological
symptoms associated with chronic pain
  • Evidence Based Medicine
  • Common Mistakes

Antidepressants        Escitalopram        Lexapro®
Escitalopram (Lexapro) is recommended as a first-line treatment option for major
depressive disorder, as a selective serotonin reuptake inhibitor (an antidepressant
medication used to treat depression and anxiety
  • Evidence Based Medicine
  • Common Mistakes

Antidepressants        Fluoxetine        Prozac®
ODG criteria, the role of fluoxetine is recommended as a first-line treatment option for
major depressive disorder with recommendations not supporting its use for the treatment
of chronic pain
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Fluvoxamine         Luvox
Official Disability Guidelines antidepressants are recommended, although not generally
as a stand-alone treatment. Antidepressants have been found to be useful in treating
depression, including depression in physically ill patients, as well as chronic headaches
associated with depression
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Milnacipran        Savella/Ixel®
(ODG), Savella is under study as a treatment for fibromyalgia syndrome. An FDA Phase
III study demonstrated "significant therapeutic effects" of milnacipran for treatment of
fibromyalgia syndrome. Milnacipran has been approved for the treatment of depression
outside of the U.S. and is a dual serotonin-and norepinephrine-reuptake inhibitor (SNRI)
.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Paroxetine         Paxil
Not recommended as a treatment for chronic pain, but SSRIs may have a role in treating
secondary depression. Selective serotonin reuptake inhibitors (SSRIs), a class of
antidepressants that inhibit serotonin reuptake without action on noradrenaline, are
controversial based on controlled trials.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Sertraline        Zoloft®
Zoloft is the brand name version of sertraline, which is an antidepressant classified as a
selective serotonin reuptake inhibitor (SSRIs). MTUS states regarding SSRIs, "Not
recommended as a treatment for chronic pain, but SSRIs may have a role in treating
secondary depression.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Venlafaxine        Effexor®
According to the Official Disability Guidelines, antidepressants are recommended for the
initial treatment of major depressive disorder. Many treatment plans are noted to start
with SSRIs, but other depressant medications that are likely to be optimal for most
patients include desipramine, nortriptyline, bupropion, and venlafaxine
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidepressants        Venlafaxine ER        Effexor XR®
Venlafaxine (Effexor): FDA-approved for anxiety, depression, panic disorder and social
phobias. Off-label use for fibromyalgia, neuropathic pain, and diabetic neuropathy.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidiabetics        Acarbose        Precose
Acarbose is used to treat type 2 diabetes. Acarbose works by slowing the action of certain
chemicals that break down food to release glucose into the body.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antidiabetics        Exenatide        Byetta
the ODG, Diabetes section, Exenatide (Byetta) is "recommended as second-line treatment
of type 2 diabetes, especially in patients having inadequate glucose control or with
hyperglycemia inadequately controlled with diet, exercise, and/or metformin alone."
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Gabapentin        Neurontin®,
Gabarone™
Gabapentin (Neurontin, Gabarone,  generic available) has been shown to be effective for
treatment of diabetic painful neuropathy and post -herpetic neuralgia and has been
considered as a first –line treatment for neuropathic pain
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Gabapentin ER        Gralise         
Gabapentin as a first-line treatment for neuropathic pain and effective for
The treatment of spinal cord injury, lumbar spinal stenosis, and post op pain
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Gabapentin ER        Horizant        
Gabapentin (Neurontin) has been shown to be effective for treatment of diabetic painful
neuropathy and postherpetic neuralgia and has been considered as a first-line treatment
for neuropathic pain.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Lacosamide        Vimpat®   
MTUS, and the ODG are silent in regards to this medicine. ..."
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Lamotrigine        Lamictal®      
MTUS and ACOEM Guidelines do not specifically address the use of Lamotrigine;
however, ODG Guidelines under the Pain Chapter for Lamotrigine states,
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Levetiracetam        Keppra®       
ODG states "Recommended. For adult patients with severe TBI, prophylaxis with
phenytoin is effective in decreasing the risk of early post-traumatic seizures and can be
administered ..."
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Oxcarbazepine    Trileptal®
Trileptal is an anti-convulsants medication that has demonstrated benefits in the treatment
of neuropathic pain, specifically trigeminal neuralgia
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Phenytoin        Dilantin®         
Pregabalin (Lyrica) has been documented to be effective in treatment
Of diabetic neuropathy and postherpetic neuralgia, has FDA approval for both
indications, and is considered first-line treatment for both. Pregabalin was also approved
to treat fibromyalgia.

  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Pregabalin        Lyrica®        
Pregabalin (Lyrica) has been documented to be effective in treatment
Of diabetic neuropathy and postherpetic neuralgia, has FDA approval for both
indications, and is considered first-line treatment for both. Pregabalin was also approved
to treat fibromyalgia.
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Tiagabine        Gabitril®        
"Recommended for neuropathic pain (pain due to nerve damage." There is a lack of
expert consensus on the treatment of neuropathic pain in general due to heterogeneous
etiologies, symptoms, physical signs and mechanisms.

  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Topiramate        Topamax®
Guidelines identifies documentation of neuropathic pain when other anticonvulsants have
failed, as criteria necessary to support the medical necessity of Topiramate
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)        Zonisamide        Zonegran®      
anti-epilepsy drugs (AED) are recommended for neuropathic pain. Most randomized
controlled trials for the use of this class of medication for neuropathic pain have been
directed at postherpetic neuralgia and painful polyneuropathy
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Anti-epilepsy drugs (AEDs)         Carbamazepine        Tegretol®    
Carbamazepine use is often limited because of side-effects, including ataxia, cognitive
decreases, dizziness, somnolence, CNS depression, hyponatremia, nausea and vomiting,
skin rashes (rarely Stevens -Johnson syndrome has been reported) and hematologic
disorders, including agranulycytosis and aplastic anemia. There is a black box warning
regarding development of potentially fatal blood cell abnormalities following the use of
Carbamazepine, and the drug should be discontinued
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antihypertensives        Aliskiren        Tekturna        
. The Official Disability Guidelines recommend blood pressure control in diabetes
mellitus to levels of 140/80. They recommend stepwise therapy including: -First line, 1st
choice -renin-angiotensin system blockers. -First line, 2nd addition -calcium channel
blockers. ..."
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antihypertensives        Amlodipine        Norvasc         
As noted by the FDA,  Norvasc or amlodipine is a calcium-channel blocker which can be
used either as monotherapy or combo therapy for hypertension
  • Evidence Based Medicine
  • Common Mistakes for denials in Authorization

Antihypertensives        Atenolol        Tenormin         
ODG guidelines addressed the use of Atenolol in the management of chronic pain.
Atenolol is a B-blocker that is used in the treatment of hypertension. Atenolol can also be
utilized for the treatment of migraine headache
  • Evidence Based Medicine \
  • Common Mistakes for denials in Authorization

Antihypertensives        Benazepril        Lotensin        
Drugs.com note that benazepril (Lotensin) is an ACE inhibitor. ACE stands for
angiotensin converting enzyme. Benazepril (Lotensin) is used to treat high blood pressure
(hypertension). Benazepril (Lotensin) may also be used for purposes not listed in this
medication guid
e

Antidepressants        Bupropion        Wellbutrin®


Antihypertensives        Captopril

Antihypertensives        Captopril        Capoten         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Clonidine        Catapres         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Doxazosin        Cardura        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Enalapril        Vasotec        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Hydralazine        Apresoline         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Hydrochlorothiazide        HCTZ        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Lisinopril        Zestril         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Losartan        Cozaar        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Metoprolol        Lopressor         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Minoxidil        Loniten         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Nadolol        Corgard         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Nicardipine        Cardene        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Nifedipine        Procardia         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Olmesartan        Benicar        
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Prazosin        Minipress  
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Propranolol        Inderal         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Ramipril        Altace         
Evidence Based Medicine Common Mistakes for denials in Authorization


Antihypertensives        Spironolactone        Aldactone         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Terazosin        Hytrin         
Evidence Based Medicine Common Mistakes for denials in Authorization

Antihypertensives        Valsartan        Diovan         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Amoxicillin        Amoxil         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Amoxicillin-Clavulanate        Augmentin         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Azithromycin        Zithromax         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Cefadroxil        Duricef         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Cefdinir        Omnicef         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Cefprozil        Cefzil         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Cefuroxime        Ceftin         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Cephalexin        Keflex         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Ciprofloxacin        Cipro        
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Clarithromycin        Biaxin         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Clindamycin        Cleocin        
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Dicloxacillin        Dynapen         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Doxycycline        Vibramycin, Doryx         Evidence
Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Levofloxacin        Levaquin         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Linezolid        Zyvox         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Metronidazole        Flagyl         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Minocycline        Minocin, Dynacin        
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Moxifloxacin        Avelox         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Penicillin        Veetids         
Evidence Based Medicine Common Mistakes for denials in Authorization

Anti-infectives        Sulfamethoxazole-Trimethoprim        Bactrim,
Septra         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Albuterol inhalation        Proventil®/
Ventolin®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Albuterol oral tablet        Albuterol         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Albuterol/Ipratropium        Combivent®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Beclomethasone        Qvar®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Budesonide inhalation        Pulmicort®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Ciclesonide        Alvesco®        
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Cromolyn        Cromolyn        
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Fluticasone inhalation        Flovent®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Formoterol        Foradil®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Formoterol/Budesonide        Symbicort®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Formoterol/Mometasone        Dulera®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Indacaterol        Arcapta®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Ipratropium        Atrovent®        
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Levalbuterol        Xopenex®       
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Mometasone inhalation        Asmanex®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Montelukast        Singulair®
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Omalizumab        Xolair®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Pirbuterol        Maxair®       
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Salmeterol        Serevent®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Salmeterol/Fluticasone        Advair®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Theophylline        Slo-Bid®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Zafirlukast        Accolate®        
Evidence Based Medicine Common Mistakes for denials in Authorization

Asthma medications        Zileuton        Zyflo®         
Evidence Based Medicine Common Mistakes for denials in Authorization

Atypical antipsychotics        Aripiprazole        Abilify         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Atypical antipsychotics        Quetiapine        Seroquel        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Atypical antipsychotics        Olanzapine        Zyprexa        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Atypical antipsychotics        Risperidone        Risperdal       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Alprazolam        Xanax        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Chlordiazepoxide        Librium        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Clonazepam        Klonopin        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Clorazepate                 
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Diazepam        Valium        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Estazolam        ProSom         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Flurazepam        Dalmane         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Lorazepam        Ativan       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Midazolam        Versed         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Oxazepam        Serax         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Quazepam        Doral         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Temazepam        Restoril        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Benzodiazepines        Triazolam        Halcion          
Evidence Based Medicine Common Mistakes for denials in
Authorization

Bisphosphonates        Alendronate        Fosamax®         
Evidence Based Medicine Common Mistakes for denials in
Authorizatio
n

Bisphosphonates        Etidronate        Didronel®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Bisphosphonates        Ibandronate        Boniva®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Bisphosphonates        Risedronate        Actonel®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Bisphosphonates        Risedronate        Atelvia®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Botulinum toxin        Botulinum toxin        Botox®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Botulinum toxin        Botulinum toxin        Dysport         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Botulinum toxin        Botulinum toxin        Myobloc®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Botulinum toxin        Botulinum toxin        Xeomin        
Evidence Based Medicine Common Mistakes for denials in
Authorization


Central adrenergic agonists        Clonidine, intrathecal        
Duraclon®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Dopamine agonists        Carbidopa/Levodopa        Sinemet®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Dopamine agonists        Pramipexole        Mirapex®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Dopamine agonists        Ropinirole        Requip®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Dopamine agonists/precursors        Amantadine        Symmetrel         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Gout medications        Colchicine        Colchicine         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Baclofen        Lioresal®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Benzodiazepines        N/A        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Carisoprodol        Soma®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Chlorzoxazone        Parafon Forte®, Paraflex®,
Relax™DS,Remular S™         Evidence Based Medicine Common
Mistakes for denials in Authorization

Muscle relaxants        Chlorzoxazone        Lorzone®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Cyclobenzaprine        Flexeril®, Fexmid™         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Cyclobenzaprine ER        Amrix®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Dantrolene        Dantrium®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Diazepam        Valium        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Meprobamate        Miltown       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Metaxalone        Skelaxin®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Methocarbamol        Robaxin®, Relaxin™         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants        Orphenadrine        Norflex®, Banflex®,
Antiflex™, Mio-Rel™, Orphenate         Evidence Based Medicine
Common Mistakes for denials in Authorization

Muscle relaxants        Tizanidine        Zanaflex®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasmodics)        Carisoprodol        
Soma®         Evidence Based Medicine Common Mistakes for denials
in Authorization

Muscle relaxants (Antispasmodics)        Chlorzoxazone        Parafon
Forte®, Paraflex®, Relax™DS,Remular S™         Evidence Based
Medicine Common Mistakes for denials in Authorization

Muscle relaxants (Antispasmodics)        Cyclobenzaprine        
Flexeril®, Fexmid™        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasmodics)        Metaxalone        
Skelaxin®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasmodics)        Methocarbamol        
Robaxin®, Relaxin™        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasmodics)        Orphenadrine        Norflex®,
Banflex®, Antiflex™, Mio-Rel™, Orphenate       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasticity drugs)        Baclofen        
Lioresal®        
Evidence Based Medicine Common Mistakes for denials in
Authorization


Muscle relaxants (Antispasticity drugs)        Dantrolene        
Dantrium®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasticity/ Antispasmodics)        
Benzodiazepines        N/A
Evidence Based Medicine Common Mistakes for denials in
Authorization

Muscle relaxants (Antispasticity/ Antispasmodics)        Tizanidine        
Zanaflex®      
Evidence Based Medicine Common Mistakes for denials in
Authorization

Nonprescription analgesics        Acetaminophen        Tylenol®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Nonprescription analgesics        Aspirin        Bayer®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Nonprescription analgesics        Ibuprofen        Advil®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Nonprescription analgesics        Naproxen        Aleve®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac        Voltaren®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac        Zorvolex         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Epolamine        Flector patch        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Potassium        Cataflam®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Potassium        Zipsor
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Sodium        Voltaren®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Sodium ER        Voltaren-XR®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Sodium Gel        Voltaren® Gel         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Sodium Injection        Dyloject         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac Sodium topical        Pennsaid®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diclofenac/ misoprostol        Arthrotec®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Diflunisal        Dolobid®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Etodolac        Lodine®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Etodolac ER        Lodine XL®         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Fenoprofen        Nalfon®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Flurbiprofen        Ansaid®         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Ibuprofen        Advil®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Ibuprofen        Motrin®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Indomethacin        Indocin®         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Indomethacin        Tivorbex         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Indomethacin ER        Indocin SR®         Evidence
Based Medicine Common Mistakes for denials in Authorization

NSAIDs         Ketoprofen        Ketoprofen         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Ketoprofen ER        Ketoprofen ER         Evidence
Based Medicine Common Mistakes for denials in Authorization

NSAIDs         Ketorolac        Toradol®         Evidence Based Medicine
Common Mistakes for denials in Authorization

NSAIDs         Ketorolac injection        Toradol®         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Ketorolac nasal spray        Sprix         Evidence Based
Medicine Common Mistakes for denials in Authorization

NSAIDs         Mefenamic Acid        Ponstel®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Meloxicam        Mobic®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Nabumetone        Relafen®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen        Aleve®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen        Anaprox DS®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen        Anaprox®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen        Naprosyn®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen ER        EC-Naprosyn®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Naproxen ER        Naprelan®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Oxaprozin        Daypro®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Piroxicam        Feldene®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs         Sulindac        Clinoril®       
Evidence Based Medicine Common Mistakes for denials in
Authorization
NSAIDs         Tolmetin        Tolectin DS       
Evidence Based Medicine Common Mistakes for denials in
Authorization
NSAIDs         Tolmetin        Tolectin®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

NSAIDs (non-steroidal anti-inflammatory drugs)        Celecoxib        
Celebrex®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine inj.        Buprenex®         Evidence Based
Medicine Common Mistakes for denials in Authorization

Opioids        Buprenorphine inj.        Buprenex®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine SL tab        Bupren.       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine transdermal        Butrans™         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine/Naloxone buccal film        
Bunavail®         Evidence Based Medicine Common Mistakes for
denials in Authorization

Opioids        Buprenorphine/Naloxone SL film        Suboxone®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine/Naloxone SL tab        Bupren/Nalox         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Buprenorphine/Naloxone SL tab        Zubsolv         
Evidence Based

Opioids        Butalbital combos (barbiturates)        Fioricet®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Codeine        Codeine         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Codeine/acetamin.        Tylenol #3        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl buccal        Fentora®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl buccal film        Onsolis™         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl lollipop        Actiq®      
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl nasal spray        Lazanda      
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl sublingual spray        Subsys®    
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl transdermal        Duragesic®          
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Fentanyl transmucosal        Abstral         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydrocodone ER        Hysingla        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydrocodone ER        Zohydro         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydrocodone/acetamin.        Lortab®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydrocodone/acetamin.        Vicodin®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydrocodone/ibuprofen        Vicoprofen®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydromorphone        Dilaudid®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Hydromorphone ER        Exalgo        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Levorphanol        Levo-Dromoran®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Meperidine        Demerol®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Methadone        Methadose®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Morphine        Morphine         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Morphine ER        Avinza®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Morphine ER        Kadian®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Morphine ER        MS-Contin        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Morphine ER / Naltrexone        Embeda        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Naloxone        Evzio®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Naloxone        Narcan®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone        Oxecta       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone        OxyIR®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone ER        OxyContin®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone ER/acetamin.        Xartemis XR         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone ER/Naloxone        Targiniq ER®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone/acetaminophen         Percocet®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone/aspirin        Percodan®
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxycodone/ibuprofen        Combunox       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxymorphone        Opana®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Oxymorphone ER        Opana ER®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Pentazocine lactate        Talwin        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Pentazocine/Naloxone        Talwin NX        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Propoxyphene hcl        Darvon®
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Propoxyphene napsylate        Darvon-N®    
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Propoxyphene/acetamin.        Darvocet®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Tapentadol        Nucynta™        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Tramadol        Ultram®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Tramadol ER        ConZip       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Tramadol ER        Ultram ER®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Tramadol/Acetaminophen        Ultracet®       
Evidence Based Medicine Common Mistakes for denials in
Authorization

Opioids        Ziconotide (morphine pump)        Prialt®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Oral corticosteroids        Methylprednisolone        Medrol         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Oral corticosteroids        Prednisone        Prednisone        
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Dexlansoprazole         
Dexilant®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Esomeprazole        Nexium®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Esomeprazole/Naproxen        
Vimovo         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Famotidine (H2 blocker)/
Ibuprofen        Duexis®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Lansoprazole        Prevacid®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Omeprazole        Prilosec®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Pantoprazole        Protonix®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

PPI (Proton Pump Inhibitor)        Rabeprazole        Aciphex®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Prostaglandins        Misoprostol        Cytotec®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Diphenhydramine        Benadryl
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Eszopicolone        Lunesta™         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Promethazine        Phenergan
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Ramelteon        Rozerem™        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Trazodone        Desyrel        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Zaleplon        Sonata®
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Zolpidem        Ambien®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Zolpidem        Edluar SL
Evidence Based Medicine Common Mistakes for denials in
Authorization

Sedative-hypnotics        Zolpidem ER        Ambien CR        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Stimulants (adjunctive pain medication)        Armodafinil        
Nuvigil        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Stimulants (adjunctive pain medication)        Modafinil        
Provigil®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Stimulants (adjunctive pain medication)        Sodium Oxybate        
Xyrem
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Capsaicin, topical        Qutenza         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Diclofenac Sodium Gel        Voltaren®
Gel        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Dimethylsulfoxide        DMSO         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Ketamine, topical        Ketamine        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Lidocaine, topical        Lidoderm®        
Evidence Based Medicine Common Mistakes for denials in
Authorization

Topical analgesics        Salicylate topicals        Ben-Gay         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Tumor necrosis factor (TNF) modifiers        Adalimumab        
Humira®         
Evidence Based Medicine Common Mistakes for denials in
Authorization

Tumor necrosis factor (TNF) modifiers        Etanercept        Enbrel®
Evidence Based Medicine Common Mistakes for denials in
Authorization

Tumor necrosis factor (TNF) modifiers        Infliximab        
Remicade®        
Evidence Based Medicine Common Mistakes for denials in
Authorization
Billing Code         Insurance Objection
Below a list of  IBRs / most 0 pay where the
objections were determined invalid and monies
awarded
Open links  to see why

0232T        Claims Administrator denied service indicating: “Value of the
services is included in the value of another service performed on the same day.”


0232T        Claims Administrator denied code with rationale “The charge exceeds
the Official Medical  Fee Schedule allowance”

0232T-RT
Claims Administrator denied code with rationale “ Included in another billed
procedure.”

0232T-RT and 0232T-LT
Claims Administrator reimbursed both codes with rationale “The Official Medical
Fee Schedule does not list this code. An allowance has been made for a comparable
service.”

20680        The Claims Administrator denied service with the following rational:
“Service not paid under OPPS.

20680-RT     The Claims Administrator denied service with the following
rational: “OP service status indicator Q. Q1 -Q3 payable only when not packaged
or bundled w/other services billed on same day”

24357-59 and 20610-59      Claims Administrator denied codes with
indication “no separate payment was made because the value
of the service is included within the value of another service performed on the
same day”

24357-59 and 20610-59

27425, 29877-59, 29874-59, 29875-59, and 20610-59      Claims
Administrator reimbursed CPT code 29875 in the amount $191.11 and
denied all other services billed.


29824        The Claims Administrator denied charges indicating: •Initial
EOR: “We cannot review without the necessary documentation...”Final
EOR: “Medical documentation does not support the services rendered


29848-LT, 64718-LT, 26055-LT, and 20550-59LT      Claims
Administrator denied all codes with rationale “diagnosis was invalid for the
date(s) of service reported”

29881-51     Claims Administrator denied code indicating on the
Explanation of Review “No separate payment was made because the value of
the service is included within the value of another service performed on the
same date of service.”

29882        Claims Administrator denied code indicating “Allowance is based
on Utilization Review pre-authorization”

63047-59-51

63650 and 63650-59    EOR indicates DWC Payment Reduction G1:“The
charge exceeds the Official Medical Fee Scheduled Allowance.”

63661 x 3        Claims administrator denied codes indicating on the
Explanation of Review “No separate payment was made because the value of
the service is included within the value of another service performed on the
same day””

64483-        LT    Claims Administrator denied codes indicating on the
Explanation of Review “Service/item included in the value of other services
per CCI edits. Related service could be on a separate bill .” EORs submitted
show only two codes billed, 64483 and 72275.


64493 and 64495        

64510        Claims Administrator denied service indicating on the
Explanation of Review “ This service appears to be unrelated to the patients
diagnosis”

64520        Claims Administrator denied code with rationale “revenue codes
and other packaged procedures are not separately
Reimbursable and are to be packaged into other services when billed on an
outpatient basis”

64718-59    Claims Administrator denied code indicating “no separate
payment was made because the value of the service is included within the
value of another service performed on the same day”

72070 and 72110    Claims administrator denied codes indicating on the
Explanation of Review “The charge was denied as the report/documentation
does not indicate that the procedure was performed.”

72275-26-59    Claims Administrator denied code indicating on the
Explanation of Review “The appended modifier code is not appropriate with
the service billed”

73721        The Claims Administrator denied service as unauthorized.

76942        The Claims Administrator denied reimbursement for 76942
stating: “Incidental to Procedure,” and  “rarely, if ever, performed.”

90792,Psychiatric diagnostic evaluation     Claims Administrator denied
code indicating “The charge was denied as the report/documentation does
not indicate that the service was performed

90833        

90837        Claims Administrator denied code indicating on the Explanation
of Review “CPT code submitted is based on service time and documentation
does not support the time spent on this procedure”

90837        Claims Administrator denied code indicating on the Explanation
of Review “CPT code submitted is based on service time and documentation
does not support the time spent on this procedure”


90837 x 4 units     Claims Administrator denied 90837 service stating: “Per
CCI Edits, the value of this procedure is included in the value of the
comprehensive procedure.”

90880

95886 and 95913        Claims Administrator denied reimbursement
indicating “charge is denied as the service was not
Authorized during the Utilization Review process
.

95913        Claims Administrator denied code with indication “The testing
results are needed in order to review this charge”

95913 and 95937        EOR’s indicate service 95913 down-coded to reflect
“contract rate.”

95937        Claims Administrator denied code indicating on the Explanation
of Review “This service appears to be unrelated to the patient’s diagnosis


95937        Claims Administrator denied code 95937 indicating on the
Explanation of Review “code 95937 is reported once per each nerve. Code

95937 cannot be reported for bilateral (modifier 50) studies.

96101 and WC007        Claims Administrator denied 96101 with rationale
“Per CCI edits, the value of this procedure is included in the value of the
comprehensive procedure”

96101-59 and 99354     The Claims Administrator denied charges as
“included” in the value of other services performed on the same day.

96101-59, 96102, 90899, and WC007    The Claims Administrator denied
codes with rationale


96118-59    Claims Administrator denied code indicating on the Explanation
of Review “CCI: Standards of Medical/Surgical Practice” and “included
within the value of another service performed on the same day”

97110-GP    The Claims Administrator’s reimbursement rational indicates:
“Contract Rate.”

97113-59        Claims administrator denied code indicating on the 1st
Explanation of Review “ please provide chart notes or office notes so we can
proceed with the correct payment

97140        Service denied by Claims Administrator as “Mutually exclusive
procedures.”

97530 x 4 Units

97530-59    Claims Administrator denied codes and indicated on the
Explanation of Review “Per CCI edits, the value of this procedure is
included in the value of the mutually exclusive procedure.”

97530-59 and 97750-59    97530 and 97750 are both time based codes each 15
minutes.•Claims Administrator denied codes and indicated on the
Explanation of Review “Per CCI edits, the value of this procedure is
included in the value of the comprehensive procedure.”

97545        The Claims Administrator denied reimbursement as “not
reimbursable under Medicare Hospital Outpatient Fee Schedule.”

97545


97750        EOR’s indicate charges “exceeded the scheduled allowance.”

97750        Claims administrator reimbursed $956.41 indicating on the
Explanation of Review “Pricing reductions due to MPN
97750 x 12        EOR does not indicate 97750 as unauthorized but does state
“No separate payment was made because the value of  The service is
included within the value of another service performed on the same day”

97750 x 32        

97799-86

97799-86

97799-86

97799        

97799        Claims Administrator reimbursed $5131.95 indicating on the
Explanation of Review “Approved by Utilization Review”

97799 Sample: Progress Notes for FRP        Claims Administrator
reimbursed $5131.95 indicating on the Explanation of Review “Approved by
Utilization Review”

97799 86 Initial Interdisciplinary Evaluation        Reduction not stated

97799 -86 60% PPO         Claims Administrator denied FRP services stating,
“The Official Medical Fee Schedule does not list code. Multiple Procedure
Payment Rule Applied”

97799-86    Claims Administrator reimbursed $2538.00 indicating on the
Explanation of Review “Reimbursement for physical medicine procedures,
modalities, including Chiropractic Manipulation and acupuncture codes are
limited to 60 minutes per visit wthout prior authorization pursuant to
Physical Medicine rule 1?”empathy


97799-86
Functional Restoration Evaluation        The Claims Administrator’s
reimbursement rational indicates the following: “This charge was adjusted
to comply with the rate and rules of the contract indicated.”

97799-86
Initial Evaluation -Functional Restoration Evaluation        

97799-86
Initial Functional Restoration Evaluation        

97799-86
Initial Functional Restoration Program        The Claims Administrator’s
reimbursement rational indicates the following: “This charge was adjusted
to comply with the rate and rules of the contract indicated.”

97799-86        Initial Evaluation - Functional Restoration Evaluation

97799-86Functional Restoration Evaluation      EOR indicate The Claims
Administrator’s reimbursement was based on “Physical Medicine” and
“negotiated rate.”

97799-86
Claims Administrator denied FRP services stating, “The billing has
exceeded the fee schedule guidelines for payment of physical therapy or
physical medicine treatment.”

97799-86
Claims Administrator denial rational: “Documentation to substantiate this
charge was not submitted or is insufficient to accurately review this charge.”

97799-86
Claims Administrator denial rational: “This is an unlisted procedure.
Please resubmit the bill with a more descriptive code or documentation.”

97799-86
Functional Restoration Evaluation        EOR indicate services denied as “not
authorized by utilization and review


97799-86
The Claims Administrator denied reimbursement with the following
rational: “The defendant disputes whether the treatment is reasonable or
necessary

97799-86
The Claims Administrator denied reimbursement as “not medically
necessary.”

97799-86
EOR indicate services denied as “not authorized by utilization and review.”

97799-86  One Day Multidisciplinary Evaluation
The Claims Administrator denied reimbursement as “not medically
necessary

97799-86

97799-86 Initial Functional Restoration Evaluation services

97799-86    The Claims Administrator denied reimbursement with the
following rational: “The defendant disputes whether the treatment is
reasonable or necessary

97799-86
•The Claims Administrator denied reimbursement as “unlisted procedure.”

97799-86     •The Claims Administrator denied reimbursement as
“Preauthorization is required for this service or procedure.”

97799-86 Initial valuation”  regarding a “Functional Restoration Program
Claims Administrator reimbursement rational -as reflected on EOR as
follows: “Charges reduced in accordance with base allowance per the
applicable fee schedule.”

97799-86 Initial Interdisciplinary Evaluation

97799-86

97799-86

97799-86
The Claims Administrator’s reimbursement rational indicates “pre-
negotiated agreement” and “contract” indicated.

97799-86 (27 units)

97799-86.        The Claims Administrator denied reimbursement as
“unlisted procedure.”

97799-86x 5
Claims Administrator denied code for three dates of service indicating on
the Explanation of Review “Unlisted/BR svc not documented. Payment
requires documentation explaining the service. See OMFS instructions for
Procedures without Unit Values.”
97813, 97814, 97110


Claims Administrator denied codes with rationale “
•Many therapy services are time-based codes, i.e., multiple units may be billed for
a single procedure . The MPPR applies to the Practice Expense (“PE”) payment
when more than one unit or procedure is provided to the same patient on the same
day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full
payment is made for the unit or procedure with the highest PE payment. Full
payment is made for the work and  malpractice components and 50 percent
payment is made for the PE for subsequent units and procedures, furnished to the
same patient on the same day

99199        •Initial, subsequent and final EOR’s reflect the Claims
Administrator denied reimbursement with the following rational: “Service
has a relative value of zero”


99199        Initial, subsequent and final EOR’s reflect the Claims
Administrator denied reimbursement  with the following rational: “Service
has a relative value of zero


99204 and WC007        The Claims Administrator denied services in full due
to “absence of pre-certification.”

99204 and WC007        The Claims Administrator denied service in full
stating, “Claim Settled, no open medical treatment allowed
99204 and WC007-30   The Claims Administrator denied service as follows:
•99204 “included in the value of another service,”
•WC007 “report does not appear to be requested...”

99205-25
,
99354

99205        The Claims Administrator’s denied service as not authorized

99205        Claims Administrator denied code indicating not authorized

99205        •The Claims Administrator’s denied service as not authorized


99205-25
The Claims Administrator’s denied service as not authorized
99214        The Claims Administrator denied reimbursement due to “billing
E/M codes is limited to physicians, physician assistants or nurse
practitioners, therefore this service is not reimbursed”

99214 and WC002        Letter to Provider from The Claims Administrator
dated 7/31/2015 & 08/15/2015 denied services with the following rational:
“The provider was not cert5ified/eligible to be paid for this
procedure/service on this date of service.


99214 and WC002        The Claims Administrator denied reimbursement
due to “Duplicate claim/service”

99214 and WC002        The Claims Administrator denied the service based
on unauthorized service.

99215 and WC002        The Claims Administrator’s denied reimbursement
due to unauthorized services

99215 and WC002        The Claims Administrator denied services as
unauthorized.

99215 and WC002        The Claims Administrator denied services as
“unauthorized.”

99215 and WC002
The Claims Administrator’s denied reimbursement due to unauthorized
services

99215, WC002, and J3490 x 2        Claims Administrator denied codes with
rationale not authorized.

99215-25
Claims Administrator denied code with rationale “The visit or service
billed, occurred within the global surgical period and is not separately
reimbursable”

99215-25, 62370, and 76942-26
Claims Administrator denied services indicating on the Explanation of
Review “No separate payment was made because the value of the service is
included within the value of another service performed on the same day”

99215-25, WC002, G0434, 96101, and  99358 x 2
Claims Administrator’s denial rationale “Services not provided or
authorized by designated (Network) Providers”

99354        •The Claims Administrator denied services based on
documentation.

99354 and 99355

99354 and 99355        The Claims Administrator denied 99354 and 99355 due
to insufficient information to adjudicate claim.

99354 and 99355        The Claims Administrator denied services based on
documentation.

99354, 99355, 99358, and 99359
•Claims Administrator denied service with the following rational:
•99354 & 99355: Report/documentation does not indicate service was
performed.

•99358 & 99359 “No Separate payment was made because the value of the
service is included within the value of another service performed on the
same day.”

99354, 99355, and 99359        Claims Administrator denied service with the
following rational:

•99354 & 99355: “Documentation provided does not justify payment for a
Prolonged Evaluation and Management service.


•99359 “No Separate payment was made because the value of the service is
included within the value of another service performed on the same day.”

99358        Services Bundled

99358 and 99080        •Claims Administrator denied codes indicating on the
Explanation of Review “service has a relative value of zero and therefore no
payment is due  ”

99358 and 99359        Claims Administrator denied 99358 and 99359 with the
following rational: “According to the Fee Schedule, this charge is not
covered.”

99358 and 99359        Claims Administrator denied codes indicating on the
Explanation of Review “According to the Official Medical Fee Schedule,
this service has a relative value of zero


99358 and 99359         •The Claims Administrator denied services indicating
“charge not covered per OMFS.”

•Opportunity to Dispute communicated to Claims Administrator on
02/29/2016 , response not yet received.

99358 and 99359        Provider seeking remuneration 99358 Prolonged
Services W/O face -to-face contact and add-on code 99359 each additional 30
minutes (list separately). •The Claims Administrator denied services
indicating “This code is either not valid or not available in the California
Fee Schedule.”

99359        The Claims Administrator reimbursed 1 of 11 units indicating
“scheduled allowance.”

99359        The Claims Administrator reimbursed 1 of 11 units indicating “
scheduled allowance.”

99499-86

99499        Claims Administrator denied reimbursement with the following
rationales: “If a flat rate has been agreed upon for the Functional
Restoration Program, please provide a signed adjuster agreement”

99499
Functional Restoration Evaluation
Claims Administrator denied reimbursement with the following rational:
“The Unlisted or BR service was not received or sufficiently identified or
documented...”

99499        The Claims Administrator based $0.00 reimbursement on
“negotiated rate”.

99499-86
SBR by Claims Administrator resulted in “duplicate claim” with upheld
recommended allowance of “$0.00,”
•Initial EOR indicated “documentation” required for reimbursement.

99499-86
Claims Administrator postponed payment post documentation review.

Billing rules:
Arthroscopic synovectomy of the knee       
DRG 472        The Claims Administrator indicates Provider “paid correctly
per fee schedule and (Claims administrator) PPO contract. Additionally, the
Claims Administrator asserts the Provider has yet to contact (Claims
Administrator) regarding contractual payment allowance.

E1339-LL        Claims Administrator re-assigned E1399-LL (lease) to E0730
NU(new it)indicating: “Based on review services rendered to be best
described by this code "E0730."

E1339-LL
Decision After Appeal Initial IBR Decision     Provider submitted appeal of
original denial of E1399 for no authorization to the Workers’
Compensation Appeals Board.

E1339-LL
Claims Administrator denied code indicating on the Explanation of Review
“not authorized”

E1339-LL
Claims Administrator denied code indicating on the Explanation of Review
“not authorized

E1399-LL
The Claims Administrator’s denial rational: “In order to review this charge
we will need a copy of the invoice

G0260        

G0260 and 20610        The Claims Administrator “$0.00” reimbursement for
G0260 and 20610 rationale based on “Payment for this charge is not
recommended per our Utilization Management Department” and “Denied
per Adjuster”

G6041, G6045, G6046, and G6056
EORs indicate laboratory results reflecting Provider’s place of business is
required for  determination
and consideration of  reimbursement
.

J7324-LT
Claims Administrator reimbursed NDC with rationale “The charge exceeds
the Medi-Cal pharmacy fees for Workers’ Compensation prescriptions”

L0637        The Claims Administrator denied service with the following
rational:  “In order to review this charge, we will need a copy of the invoice,
” citing 5307.1 (e).

L1990        Claims Administrator denied reimbursement with the following
rational:“This item is packaged or bundled into another basic service.”

L3908-RT-LT and L1832-LT
Claims Administrator denied codes indicating “Payment denied/reduced for
absence of precertification/ authorization.

L6034 (Rev Code 0274)

Ml Reports         ML100        •ISSUE IN DISPUTE: Provider seeking
remuneration for ML100 Missed Med-Legal

ML100        Claims Administrator denied billed code with indication
“Medical Legal missed appointment code used for communication purposes
only”

ML101-93-95   ML101-92

ML101        Claims Administrator reimbursed $3403.13 from total billed
amount $6187.50 with rationale “excessive billing, and asserts that
approximately 45% of the 66 page report includes commentary outside
Provider’s area of expertise

ML101-94
Claims Administrator denied reimbursement based on “criteria.”

ML101        The Claims Administrator indicates ML101 units reduced based
on submitted report.

ML101-94, 96100
EOR 11/19/2013 reflects reimbursement by Claims Administrator in the
amount of $168.24. Reimbursement rational: “Amounts billed above the
payment or the recommend allowances as shown, are hereby objected to as
being in excess of amounts authorized under Labor Code...”

ML101-95
Claims Administrator denied services indicating: “Provider does not
participate in MPN.”

ML101-95
Claims Administrator denied services indicating: “Payment denied/reduced
for absence of, or exceeded, pre-certification/authorization.”

ML101-95, ML104-95
The Claims Administrator denied initial ML101-95 reimbursement with
the following rational:•Please remit initial ML report.

ML102        The Claims Administrator based reimbursement on 99214,
Established Patient Evaluation and WC004
Primary Treating Physician Permanent and Stationary Report, as “more
appropriate.”

ML102-95-93
Claims Administrator denied code indicating “the charge was denied as the
report/documentation does not indicate that the service was performed”

ML103-86
Claims Administrator reimbursed ML 103 as 99205 indicating on the
Explanation of Review “The documentation does not support the level of
service billed. Reimbursement was made for a code that is supported by the
documentation submitted with the billing”

ML103-94
Claims Administrator reimbursed $324.83 after changing ML 103 to 99215
and WC004.

ML104-93


ML104
The Claims Administrator denied ML104 for the following reasons:  
“Unauthorized.”

ML104        
ML104        Claims Administrator denied reimbursement with rationale
“This workers’ compensation claim has been denied”

ML104        Claims Administrator denied ML 104 with rationale “Claim is
denied. No payment will be made.”

ML104        Claims Administrator reimbursed ML 104 as ML 103 with
rationale “services rendered appear to be best described by this code”

ML104-95
Claims administrator down coded ML 104 to ML 103 indicating on the
Explanation of Review “Billing greater than Medical Legal Allowance” and
“Qualified Medical Examiner”

ML104        Claims Administrator denied services with the following
rational: “No Reimbursement was  made for the E/M services as the
documentation does not support a separate significant identifiable E&M
service performed with other services provided. Plan Procedures not
followed.”


ML104 and 96101        The Claims Administrator denied reimbursement
pending documentation

ML104 x 38        ML104, 73110, 72110, 73562, 73030 and 72040
Claims Administrator ML104 reimbursement rational: “FCE Not
Requested,” and “Not Authorized.”

ML104-86-92
The Claims Administrator based reimbursement on “better defining
service,” 99215 Established Patient Evaluation

ML104-86-92
(ML by PTP)         •The Claims Administrator based reimbursement on
“better defining service,” 99215 Established Patient Evaluation

ML104-92
Claims Administrator denied reimbursement for services with the following
rational: “Documentation does not support the level of service billed.”

ML104-92   ML104-92 (ML by PTP Requited by Applicant)
Claims Administrator reimbursed Down-coded the service to Evaluation and
Management  Code 99215, stablished Patient, and California Reporting
Code WC004,  Primary Treating  Physician's Permanent and. Stationary
Report based on the following rational: “The Official Medical Fee Schedule
Does Not List This Code. An Allowance has been made for a comparable
service

ML104-94
The Claims Administrator reimbursed ML 104-94 however,  down-coded
total units based on elements of report.

ML104-94
Claims Administrator shows an allowance of $9125.00 on the Explanation of
Review  dated 6/17/2014 for ML 104 indicating “Recommended payment of
this procedure or supply should be reimbursed only if pre-authorization has
been obtained by the Claims Examiner

ML104-94
Claims Administrator down coded ML 104 to ML 103 indicating "the
following are not considered factors or were not met: Record Review”

ML104-94
The Claims Administrator denied services requesting re-submission with
“ICD.10” coding.

ML104-94-95        •The Claims Administrator down coded ML 104 to a ML
102 and reimbursed services $781.25 with the following rational: “the
charge exceeds the Official Medical Fee Schedule  allowance. The charge
has been adjusted to the scheduled allowance.” Claims Administrator
also disputing the timeliness of second bill review.

ML104-94-95
The Claims Administrator reimbursed $4,250.00 with
rationale “reasonable charges on this case would be 17 hours x 4 =68 units


ML104-95   
The Claims Administrator down-coded the billed ML104-95 to ML103 with
the following explanation: “The documentation does not support the level
of service billed. Reimbursement was made for a code that is supported by
the documentation submitted with the billing.”

ML104-95
The Claims Administrator denied service with the following rational: “The
Patient cannot be identified as having a claim against this Claims
Administrator.”

ML104-95

ML104-95
Claims Administrator reimbursed $62.50 of the billed total $2625.00 with
indication of  “the charge exceeds the Official Medical Fee Schedule
Allowance. The charge has been adjusted to the scheduled allowance

ML104-95
Claims Administrator down coded ML 104 to ML 103 with rationale “Report
does not meet 4 or more complexity factors listed under ML 104 as required
by Title 8 CCR 9795”

ML104-95
Claims Administrator reimbursed 27 units for a total of $1687.50 of the 99
units billed.

ML104-95
The Claims Administrator reimbursed the Provider “$1,625.00” of  
“$3,812.50, ”indicating “Official Medical Fee Schedule” rational.
•EOR’s do not indicate ML104level of services down-coded or denied.

ML104-95
Claims Administrator denied service with rationale “Alternative services
were available and should have been utilized

ML104-95
Claims Administrator down coded ML 104 to a ML 103and reimbursed
Services $937.50 with the following rational: “the charge exceeds the
Official Medical Fee Schedule allowance. The charge has been adjusted to
the scheduled allowance
.

ML104-95
Claims Administrator down coded ML 104 to a ML 103
And reimbursed services $843.75 with the following rational:
“documentation doesn’t support the level of service.

ML104-95
The Claims Administrator denied ML104 indicating “Charge exceeds the
Official medical Fee Schedule allowance.”

ML104-95
Claims Administrator reimbursed $7125.00 indicating “20 hours billed for
records review is a bit excessive”and only reimbursed Provider for 14.5
hours.

ML104-95-25
Claims Administrator denied service originally. A third EOR submitted by
Claims Administrator after the dispute had been filed, shows ML 104
processed with a payment to be made to Provider in the amount of $4125.00

ML106        EOR indicate services denied to “insufficient information”
required to adjudicate claim.

ML106        Communication from the Claims Administrator dated
November 2, 2015 requesting a reexamine of the injured worker as a Panel
Qualified Medical Examiner with a list of directives to submit in his report
was submitted for this review.

ML106-95

ML106-94
Claims Administrator reimbursed Provider $2,968.75 and then re-cooped
funds for service.

ML106-95
Claims Administrator reimbursed ML 106 and a separate 99080 which was
denied payment.

ML106-96        The Claims Administrator denied reimbursement pending
“authorization.”

NCD's 38779-0082-09, 63275-9913-09, 51552-1285-08
Claims Administrator provided the following explanation for denial: “non
FDA approved agent, therefore is considered non reimbursable.”

Telephone call services (99371-99373)        

WC002 and 99215        
WC002 and 99215        Claims Administrator denied codes indicating on the
Explanation of Review “Provider not authorized to bill for proc/svc”
WC004        The Claims Administrator denied the service with the following
rational: “This report does not fall under the guidelines of separately
reimbursable reports.”

WC004 and 99215-17
The Claims Administrator denied services as not authorized.

WC004 x 8 and 99499 x 8        WC007         •The Claims Administrator
denied service in full stating, “a charge was made or a separate procedure
that does not meet the criteria for separate payment. See Physician ’s Fee
Schedule Gen.”

WC007-30
The Claims Administrator denied service with rationale “The visit or
service billed occurred within the global surgical period and is not
separately reimbursable.”
The Basics of Medical-Legal Evaluations
By Richard J Boggan JD /06062016



ML Requested by Injured Worker
: “Provider, an Orthopedic Specialist, was requested by Legal Parties in
the matter of (Injured Worker)”        (This taken from an IBR decision
that awarded ML-104 illustrates that the injured worker can request the
PTP or QME to do a ML )

ML 100:  Missed Appointment for a Comprehensive or Follow-
Up Medical-Legal Evaluation. This code is designed for communication
purposes only. It does not imply that compensation is necessarily owed.

ML 101: Follow-up Medical-Legal Evaluation.

ML101Med. Legal Definition:

Example of ML 101 Disallowed

ML102 Definition: A basic medical evaluation which does not meet
the criteria of any other medical-legal evaluation. Paid at a flat rate of
$625.00 (this normally happens when a ML was requested by party but
none of format and information required for ML101, 103 or 104 are met)

ML 103: Complex Comprehensive Medical-Legal
Evaluation. Includes

ML 104: Complex Comprehensive Medical-Legal
Evaluation. Includes evaluations which require four of the complexity
ML100        •ISSUE IN DISPUTE: Provider seeking remuneration for
ML100 Missed Med-Legal
ML100     

ML100        Claims Administrator denied billed code with indication
“Medical Legal missed appointment code used for communication
purposes only”

ML101        Claims Administrator reimbursed $3403.13 from total billed
amount $6187.50 with rationale “excessive billing, and asserts that
approximately 45% of the 66 page report includes commentary outside
Provider’s area of expertise

ML101-94
Claims Administrator denied reimbursement based on “criteria.”

ML101        The Claims Administrator indicates ML101 units reduced
based on submitted report.

ML101-95
Claims Administrator denied services indicating: “Payment
denied/reduced for absence of, or exceeded, pre-
certification/authorization.”

ML102        The Claims Administrator based reimbursement on 99214,
Established Patient Evaluation and WC004
Primary Treating Physician Permanent and Stationary Report, as “more
appropriate.”

ML102-95-93
Claims Administrator denied code indicating “the charge was denied as
the report/documentation does not indicate that the service was
performed”

ML103-86
Claims Administrator reimbursed ML 103 as 99205 indicating on the
Explanation of Review “The documentation does not support the level
of service billed. Reimbursement was made for a code that is supported
by the documentation submitted with the billing”

ML103-94
Claims Administrator reimbursed $324.83 after changing ML 103 to
99215 and WC004.

ML104        Claims Administrator denied reimbursement with rationale
“This workers’ compensation claim has been denied”

ML104        Claims Administrator denied ML 104 with rationale “Claim
is denied. No payment will be made.”

ML104        Claims Administrator reimbursed ML 104 as ML 103 with
rationale “services rendered appear to be best described by this code”

ML104-95
Claims administrator down coded ML 104 to ML 103 indicating on the
Explanation of Review “Billing greater than Medical Legal Allowance”
and “Qualified Medical Examiner”

ML104        Claims Administrator denied services with the following
rational: “No Reimbursement was  made for the E/M services as the
documentation does not support a separate significant identifiable E&M
service performed with other services provided. Plan Procedures not
followed.”


ML104 and 96101        The Claims Administrator denied reimbursement
pending documentation

ML104,73110, 72110, 73562, 73030 and 72040
Claims Administrator ML104 reimbursement rational: “FCE Not
Requested,” and “Not Authorized.”

ML104-86-92
The Claims Administrator based reimbursement on “better defining
service,” 99215 Established Patient Evaluation

ML104-86-92
(ML by PTP)         •The Claims Administrator based reimbursement on
“better defining service,” 99215 Established Patient Evaluation

ML104-92 (ML by PTP Requited by Applicant)
Claims Administrator reimbursed Down-coded the service to Evaluation
and Management  Code 99215, stablished Patient, and California
Reporting Code WC004,  Primary Treating  Physician's Permanent and.
Stationary Report based on the following rational: “The Official Medical
Fee Schedule Does Not List This Code. An Allowance
has been made for a comparable service

ML104-94
Claims Administrator shows an allowance of $9125.00 on the
Explanation of Review  dated 6/17/2014 for ML 104 indicating
“Recommended payment of this procedure or
supply should be reimbursed only if pre-authorization has been
obtained by the Claims Examiner

ML104-94
Claims Administrator down coded ML 104 to ML 103 indicating "the
following are not considered factors or were not met: Record Review”

ML104-94
The Claims Administrator denied services requesting re-submission with
“ICD.10” coding.

ML104-94-95        •The Claims Administrator down coded ML 104 to a
ML 102 and reimbursed services $781.25 with the following rational:
“the charge exceeds the Official Medical Fee Schedule  allowance. The
charge has been adjusted to the scheduled allowance.” Claims
Administrator also disputing the timeliness of second bill review.

ML104-94-95
The Claims Administrator reimbursed $4,250.00 with
rationale “reasonable charges on this case would be 17 hours x 4 =68
units ”

ML104-95

ML104-95
Claims Administrator reimbursed $62.50 of the billed total $2625.00
with indication of  “the charge exceeds the Official Medical Fee Schedule
Allowance. The charge has been adjusted to the scheduled allowance

ML104-95
Claims Administrator down coded ML 104 to ML 103 with rationale
“Report does not meet 4 or more complexity factors listed under ML
104 as required by Title 8 CCR 9795”

ML104-95
Claims Administrator reimbursed 27 units for a total of $1687.50 of the
99 units billed.

ML104-95
The Claims Administrator reimbursed the Provider “$1,625.00” of  
“$3,812.50, ”indicating “Official Medical Fee Schedule” rational.
•EOR’s do not indicate ML104level of services down-coded or denied.

ML104-95
Claims Administrator denied service with rationale “Alternative services
were available and should have been utilized

ML104-95
Claims Administrator down coded ML 104 to a ML 103and reimbursed
Services $937.50 with the following rational: “the charge exceeds the
Official Medical Fee Schedule allowance. The charge has been adjusted
to the scheduled allowance
.

ML104-95
Claims Administrator down coded ML 104 to a ML 103
And reimbursed services
$843.75 with the following rational: “documentation doesn’t support
the level of service
.
ML104-95
The Claims Administrator denied ML104 indicating “Charge exceeds the
Official medical Fee Schedule allowance.”

ML104-95
Claims Administrator reimbursed $7125.00 indicating “20 hours billed
for records review is a bit excessive”  and only reimbursed Provider for
14.5 hours.

ML104-95-25
Claims Administrator denied service originally. A third EOR submitted
by Claims Administrator after the dispute had been filed, shows ML
104 processed with a payment to be made to Provider in the amount of
$4125.00

ML106-95

ML106-94
Claims Administrator reimbursed Provider $2,968.75 and then re-
cooped funds for service.

ML106-95
Claims Administrator reimbursed ML 106 and a separate 99080 which
was denied payment
.

ML106-96        The Claims Administrator denied reimbursement
pending “authorization.”
All the Information On This Page is
A Table Of Contents of What is
Included in the Book in Detail and
Put Forth in full
WC: Texas Compound Medications:
Texas Through a Process Created A System That
By-Passes Medical Necessity /Authorization, for
Compound Medications
Presently Posted Information
California: More Liberal in finding Compound
Reasonable and Necessary: Below samples:
New: Pleadings: New Case Law That Makes
90% of Non-Appearance Excusable see sample
response  Response to "Notice of Intent to
Dismiss For Non-Appearance:
New: Panel Decision Clarifies most MPN
defenses for ancillary services invalid
New: Law Defines Last Date of Services to All
Treatment and Services extends lien filing times
:
New: Urine Drug Screen IBRs and MFDR
Clarifies DOS 2015 Average Reimbursement  
$275.00 to $573.00
NEW: WC: Providers Monies; "Work Comp,
Only Place You Can Do The Work And Not Get
Paid", A Statement More Common Than Not.
New: Issues in denied case Laws and Citations
07132016 by Richard J Boggan        Instructions:

Settlements in denied cases are one of convenience,
1.        There are cases initially denied then admitted for that below CNA case to get usual
and customary
2.        However, most cases that are denied are resolved by C&R, when that happens to
get usual and customary the Provider has to overcome the defense for the denial which ca
be done 90% of the time, by knowing the laws regarding common defense listed below
3.        To get usual and customary takes a demand with cited cases below  and or
pleadings  briefs using the laws cited below
Issues in denied case Laws and Citations 07132016 by Richard J Boggan
Instructions:
Settlements in denied cases are one of convenience,
1.        There are cases initially denied then admitted for that below CNA case to get usual
and customary
2.        However, most cases that are denied are resolved by C&R, when that happens to
get usual and customary the Provider has to overcome the defense for the denial which ca
be done 90% of the time, by knowing the laws regarding common defense listed below
3.        To get usual and customary takes a demand with cited cases below  and or
pleadings  briefs using the laws cited below
Name or Username:
Your email address:
Your phone number:
Question and action
required
Member Ask Any question
regarding any issue and
receive immediate answer
with supporting law
Documentation
Payment Issue
Authorization
Inpatient Detoxification
Evidence Based Medicine Guidelines
Inpatient Detoxification
Billing Codes / Common Objections
Payment Issues and What Should Be
Paid and Why
Inpatient Detoxification
Common Documentation Errors and
Reason for Denials
Documentation
Payment Issue
Aquatic Therapy
Evidence Based Medicine Guidelines
Documentation
Payment Issue
Authorization
Arthroscopic decompression
Evidence Based Medicine Guidelines
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Biofeedback Evidence Based Medicine
Guidelines
Biofeedback Billing Codes / Common
Objections Payment Issues and What
Should Be Paid and Why
Biofeedback Common Documentation
Errors and Reason for Denials
Documentation
Payment Issue
Authorization
Bone growth simulator Evidence Based
Medicine Guidelines
Bone growth simulator Billing Codes /
Common Objections Payment Issues and
What Should Be Paid and Why
Bone growth simulator  Common
Documentation Errors and Reason for
Denials
Documentation
Payment Issue
Authorization
Botox injection Evidence Based
Medicine Guidelines
Botox injection Billing Codes / Common
Objections Payment Issues and What
Should Be Paid and Why
Botox injection Common
Documentation Errors and Reason for
Denials
Documentation
Payment Issue
Authorization
Authorization
Carpal Tunnel Release Evidence Based
Medicine Guidelines
Carpal Tunnel Release Billing Codes /
Common Objections Payment Issues and
What Should Be Paid and Why
Carpal Tunnel Release Common
Documentation Errors and Reason for
Denials
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Electromyography (EMG) Evidence
Based Medicine Guidelines
Electromyography (EMG) Billing Codes /
Common Objections Payment Issues and
What Should Be Paid and Why
Electromyography (EMG)  Common
Documentation Errors and Reason for
Denials
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization


.Video Fluoroscopic Evaluation of the Shoulders (with motion).....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Viscosupplementation injections.....
•         Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Voltage-Actuated Sensory Nerve Conduction Threshold of Lumbar Spine...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Weight loss program...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work conditioning...
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work Conditioning Program physical therapy....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

Work Harding Screening "......
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....

X-Rays Guidelines state.....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues...
.

Yoga Sessions .....
•        Criteria (Clinical  documentation)....
•        Common Errors:...
•        Billing Codes and Payment Issues....
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
Documentation
Payment Issue
Authorization
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Grove California 92846
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Incorrect or Correct  Payment Objections as Decided By
IBR-- Sign -up and receive decisions as to why below
objections were ruled incorrect

IBR Objections 10312016

Monday, October 31, 2016

6:30 PM

Billing Code

Incorrect Objections

Insurance Objection

 

Incorrect Objections

 

0232T

Incorrect Objections

Claims Administrator denied code with rationale “The charge exceeds the Official Medical  Fee Schedule allowance”

 

0232T

Incorrect Objections

Claims Administrator denied service indicating: “Value of the services is included in the value of another service performed on the same day.”

 

 

0232T-RT

 

Incorrect Objections

Claims Administrator denied code with rationale “ Included in another billed procedure.”

 

0232T-RT and 0232T-LT

 

Incorrect Objections

Claims Administrator reimbursed both codes with rationale “The Official Medical Fee Schedule does not list this code. An allowance has been made for a comparable service.”

 

20680

 

Incorrect Objections

Reimbursement for CPT code 20680 was less than expected by the Provider.

 

20680

Incorrect Objections

The Claims Administrator

denied service with the following rational: “Service not paid under OPPS.

 

20680-RT

 

Incorrect Objections

The Claims Administrator denied service with the following rational: “OP service status indicator Q. Q1

-Q3 payable only when not packaged or bundled w/other services billed on same day”

 

23412 and 23120

Incorrect Objections

Claims Administrator  denied services with“ Pre-authorization required, reimbursement denied.Visit limit has been reached”

24357-59 and 20610-59

 

Incorrect Objections

Claims Administrator denied codes with indication “no separate payment was made because the value

of the service is included within the value of another service performed on the same day”

 

27425, 29877-59, 29874-59, 29875

-59, and 20610-59

 

Incorrect Objections

Claims Administrator reimbursed CPT code 29875 in the amount $191.11 and denied all other services billed.

29822-59,29826

-59

 

Incorrect Objections

denial of codes 29822-59 and 29826-59

29824

Incorrect Objections

·The Claims Administrator denied charges indicating: ·Initial EOR: “We cannot review without the necessary documentation...”Final EOR: “Medical documentation does not support the services rendered”

 

29824 and 29822

-

59

 

Incorrect Objections

Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according  to state regs out-patient facility schedule.” Claims Administrator denied 29822 with  rationale “Service/item included in the value of other services per CCI edits

29824 and 29822-59

 

Incorrect Objections

Claims Administrator’s reimbursement rationale of CPT 29824 “H01: Priced according to state regs out-patient facility schedule.” Claims Administrator denied 29822 with rationale “Service/item included in the value of other services per CCI edits.”

29848-LT, 64718

-LT, 26055-LT, and 20550-59LT

 

Incorrect Objections

Claims Administrator denied all codes with rationale “diagnosis was invalid for the date(s) of service reported”

29881-51

 

Incorrect Objections

Claims Administrator denied code indicating on the Explanation of Review “No separate payment was made because the value of the service is included within the value of another service performed on the same date of service.”

29882

Incorrect Objections

Claims Administrator denied code indicating “Allowance is based on Utilization Review pre-authorization”

33249 and 93005

Incorrect Objections

Documentation indicates SBR requested; 2ndEOR not received.

 

63047-59-51

 

Incorrect Objections

Claims Administrator was incorrect to deny code 63047-59-51 and therefore, reimbursement is recommended.

63650 and 63650

-59

 

Incorrect Objections

EOR indicates DWC Payment Reduction G1:“The charge exceeds the Official Medical Fee Scheduled Allowance.”

63661 x 3

Incorrect Objections

Claims administrator denied codes indicating on the Explanation of Review “No separate payment was made because the value of the service is included within the value of another service performed on the same day””

63685 and 76000