Anthem Blue Cross Denying MBB anatomy

[docnyc]

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Just had a peer to peer with someone at Blue Cross who says that the L3 medial branch nerve does not innervate the L4-5 facet joint. He was stating that Bogduks anatomical model was incorrect and new NASS guidelines state that the level above does not supply innervation to the facet joint below.

Has anyone heard of this? I asked him for the NASS guidelines and he said I should look them up. We went around in circles for 20 minutes and he stated that we have a nomenclature issue.

I asked him if I want to dennervate L4-S1 facets on the left then wouldnt that correspond to ablating L3 mb, L4mb and L5 (dorsal ramus) meaning 3 needles.

He said no and stated that the needle would only go "in between the L4-5 and L5-S1 facet joints" therefore only 2 needles. When I asked him exactly "where in between L4-5 and L5-S1" he said anywhere.

????

Does anyone know of these guidelines? Wouldnt placing only two needles only dennervate one joint?

 

[Dr. Ice]

Just had a peer to peer with someone at Blue Cross who says that the L3 medial branch nerve does not innervate the L4-5 facet joint. He was stating that Bogduks anatomical model was incorrect and new NASS guidelines state that the level above does not supply innervation to the facet joint below.

Has anyone heard of this? I asked him for the NASS guidelines and he said I should look them up. We went around in circles for 20 minutes and he stated that we have a nomenclature issue.

I asked him if I want to dennervate L4-S1 facets on the left then wouldnt that correspond to ablating L3 mb, L4mb and L5 (dorsal ramus) meaning 3 needles.

He said no and stated that the needle would only go "in between the L4-5 and L5-S1 facet joints" therefore only 2 needles. When I asked him exactly "where in between L4-5 and L5-S1" he said anywhere.

????

Does anyone know of these guidelines? Wouldnt placing only two needles only dennervate one joint?

Hes an idiot and he doesnt want to pay you to do your job

 

[emd123]

They can pull any crap out of their a-- to not pay. It doesn't have to make sense. Your only recourse is to tell your patients to drop the insurance since it doesn't give them anything in return, and for you to drop out of network.

If enough do, then they have an incentive to cover things. Otherwise, they'll keep dropping things until there's nothing left to pay for.

 

[lobelsteve]

Call back and get his name. specialty, and training.

He's a tool and we can get him fired for lying.
Make sure you record the conversation.

 

[Jcm800]

Call back and get his name. specialty, and training.

He's a tool and we can get him fired for lying.
Make sure you record the conversation.

Agree. What is that nonsense

 

[101N]

If you going to post his name, do it in the physicians only forum.

 

[SSdoc33]

If you going to post his name, do it in the physicians only forum.

Why?

Is there some confidentiality issue?

Id have no problem smearing the name of some hack doctor who takes money to deny legitimate patient services. He can't even educate himself enough to understand the procedure he is denying. He took an oath to help heal the sick, when in reality, he is taking money to do just the opposite. I have no patience for that kind of crap

 

[101N]

Why?

Is there some confidentiality issue?

Id have no problem smearing the name of some hack doctor who takes money to deny legitimate patient services. He can't even educate himself enough to understand the procedure he is denying. He took an oath to help heal the sick, when in reality, he is taking money to do just the opposite. I have no patience for that kind of crap

Let's not take everything posted at face value. Good to know our facts before we 'out' someone.

 

[SSdoc33]

Let's not take everything posted at face value. Good to know our facts before we 'out' someone.

You and I wouldn't OUT him. The doc who's case it was would.

A better avenue would be Steve's. But these insurance shills are the lowest of the low. Especially when they are dead wrong.

 

[clubdeac]

What a waste of your effing time!!! This is the kind of sheeet that makes me want to stay in the VA. You should send him a bill for your time

 

[101N]

You and I wouldn't OUT him. The doc who's case it was would.

A better avenue would be Steve's. But these insurance shills are the lowest of the low. Especially when they are dead wrong.

When I had the facts I'd out him in the private forum.

 

[101N]

What a waste of your effing time!!! This is the kind of sheeet that makes me want to stay in the VA. You should send him a bill for your time

While there is nothing wrong with caring for vets - indeed it's kind of noble - you are too good to work for the VA.

 

[pmrmd]

why?

Is there some confidentiality issue?

Id have no problem smearing the name of some hack doctor who takes money to deny legitimate patient services. He can't even educate himself enough to understand the procedure he is denying. He took an oath to help heal the sick, when in reality, he is taking money to do just the opposite. I have no patience for that kind of crap

+1000000000000000000000

 

[bedrock]

Why?

Is there some confidentiality issue?

Id have no problem smearing the name of some hack doctor who takes money to deny legitimate patient services. He can't even educate himself enough to understand the procedure he is denying. He took an oath to help heal the sick, when in reality, he is taking money to do just the opposite. I have no patience for that kind of crap

+ infinity

 

[docnyc]

I have his name, and am considering out'ing him. I may try to contact Blue Cross first and I want to read through their entire policy on mbbs/rfas and see if that leads anywhere.

He's an orthopod. He was adamant on his innervation of the facet joints. I was baffled. He said the "place it where you want in between the facet joint" kind off of the cuff as I was getting annoyed and pushing back a little on having him explain the anatomy of where I would place the needle to do an RFA. The other thing was he was saying, you can "ablate the L4-5 and L5-S1 facet joints, but not the L3 medial branch nerve because it is above the joint"

WTF???

He even went so far to say "I review these all of the time and this is the policy." I asked him since when has the innervation changed anatomically for lumbar facet joints and he told me this NASS nonsense (which I cant find) I've never had such a terrible experience on a peer to peer. He said this has been Blue's policy for the past year.

I agree, what an effing waste of my time, I got so behind in my clinic trying to argue this BS.

 

[docnyc]

And, yes I will DEFINITELY let the patient know about this. Ive been letting patients know whenever the insurance companies deny something and encourage them to call customer service.

Blue keeps on changing their requirements. Before it was 2 sets of mbbs. I asked this guy on peer to peer if i have to do two separate mbbs in the future to get approval for rfas and he said no, one mbb is fine. Ive read on this forum some ppl having to do 3 sets of mbbs.

I had a derm friend of mine that wrote a crap load of appeals to overturn denial for laser treatment of a Nevus of Ota, a congenital (large birthmark) pigmented lesion on the face which is considered a medical treatment, not cosmetic. They denied it based on it being cosmetic. I only wasted 20 minutes, this friend of mine spent hours writing appeals and making calls.

 

[lobelsteve]

Have staff call back. You have a right to same specialist appeal review.

Ortho is not in scope of practice. Close but no cigar.

 

[Tenesma]

i love on peer to peers when they say "this conversation is being recorded for quality" -

I usually respond "oh good, I am recording this conversation as well"

they say "why are you recording it too?"

"for legal reasons" and then I have a long pause....

 

[stim4u]

you are right, BCBC RFA criteria is bogus and non-transparent. They told me once that i needed 2 sets of MBB blocks per year to justify a repeat RFA.... Crazy. Keep on appealing with Blue Cross (3 levels of appeal), they eventually give in, or you then threaten to take it to the Health Care Commissioner in your state. Once you do this they will not screw with you again. This happened to me about 5 years ago, and now I have no issues, although I still have a 6 month delay in payments (after internal reviews of all the records).

 

[Mister Mxyzptlk]

If you're in Texas it's legal to record a conversation if at least one party knows about it.

So if you're in Texas and they ask why you're recording the conversation you just say "Because I can".

Otherwise just say you're recording for quality assurance purposes just like them. If they ask whose quality you're tracking, reply "Yours".

 

[powermd]

I got a denial today on RFA for... wait for it...

NO PSYCH EVAL

I couldn't stop laughing on the phone with the Anthem RN.

Apparently joint pain that responds 100% to MBB might just be "psychogenic".

I told her if Anthem wants to waste the patient's time, and their money, have a blast!

We'll see what the chump "medical director" has to say.