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Coflex approvals

Started by larry56 on 09/27/2016 7:57am

Having a difficult time with insurance company approving the device/procedure 0171T to implant the coflex device. UHD has approved all other CPT and diag codes but not the actual device. Anyone else have this issue and what can be done. Peer to peer did not work and the appeal is also a waste of time.

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Hi, just joined and sharing my Coflex experience. In the 4th week of recovery now. Yes insurance is a hassle and it takes a good insurance coordinator from your surgeon's office to keep being persistent. --The new codes "sort of work," but I think it will be sometime before coverage will be automatic. ---We won in binding appeal.

For me, getting the insurance (a very major national company) to pay for the procedure is a story in and of itself. Most denials are blanket and have "canned responses" in them. But I read their denials very carefully to form the right counter argument. We finally won in binding arbitration after six months of appeals. Insurance companies try to claim the procedure is "experimental."

As part of the appeal, I carefully read and supplied 4-5 detailed studies that were “peer refereed” (the gold standard in research ....use Goggle Scholar) and argued in a synopsis that in fact Coflex is a proven technology. --The latest five yearlong study shows that outcomes were statistically significantly better than the fusion procedure, were lower cost in the long run, required less time in surgery with lower blood loss, and had fewer re-surgeries. The binding ruling that came back is that Coflex is not experimental and so they were required to pay.

--So basically, you have argue to the arbitrator that the procedure, although not as widespread, is proven and not experimental. --Good luck to you.

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I am dealing with a similar schedule. The first time there was no problem now they are denying it this time. If you could share those references I would appreciate it!

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