New low for BCBS: approved first MBB, Denied second…despite 90% relief

[GlowInTheDark]

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I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

 

[lobelsteve]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

Self pay RF or just submit for RF.

 

[DODOCSS]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

state insurance commissioner

 

[gaspasser127]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

State insurance commissoner

But out of curiosity what was the reason for the denial on the denial letter

 

[JoeLores]

Recommend they go to ER and do it in the hospital and bill insurance $10k.

 

[Ducttape]

Recommend they go to ER and do it in the hospital and bill insurance $10k.

Please don't.

As a former ER doc, nothing is more infuriating than some random patient being sent in to get something done that is not indicated then make us - ie ER docs - the bad guy for telling the patient to leave.

 

[BoardingDoc]

Please don't.

As a former ER doc, nothing is more infuriating than some random patient being sent in to get something done that is not indicated then make us - ie ER docs - the bad guy for telling the patient to leave.

Agreed. I'm sure (hopefully) that @JoeLores was being sarcastic. That said, this person will come to the ER, get a big bill for it, and we will do nothing to help them in any meaningful way. Outside of extremely uncommon circumstances they certainly won't get admitted for an MBB/LESI/<insert elective procedure here>.

 

[mdo1738]

It only took them 3 months to forget about Luigi

 

[Status Sciaticus]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

interested in learning about the reason for denial as well.

 

[GlowInTheDark]

interested in learning about the reason for denial as well.

- said I didn’t document failed Pt in last 6 months. Patient was in MVC 17 years ago, classic whiplash injury picture, failed multiple rounds of PT, chiro, reiki. Last had been done over a year ago.
- said patient’s symptoms and imaging report were more consistent with radicular pain. Nurse had documented a complaint of tingling in right hand, amongst others. My notes clearly outlined why I felt primary pain was non-radicular. ***** went on to double down that a radiculitis needs to be resolved before we could proceed with MBB. Patient had a C4-5 ILESI (yes, you read that correct) with 2 days of relief at a different center within last 6 months.

 

[gaspasser127]

- said I didn’t document failed Pt in last 6 months. Patient was in MVC 17 years ago, classic whiplash injury picture, failed multiple rounds of PT, chiro, reiki. Last had been done over a year ago.
- said patient’s symptoms and imaging report were more consistent with radicular pain. Nurse had documented a complaint of tingling in right hand, amongst others. My notes clearly outlined why I felt primary pain was non-radicular. ***** went on to double down that a radiculitis needs to be resolved before we could proceed with MBB. Patient had a C4-5 ILESI (yes, you read that correct) with 2 days of relief at a different center within last 6 months.

Typical insurance medical policy criteria

What was their justification for why the first one was approved?

 

[clubdeac]

In a similar vein I had a lady with cervical radic that I submitted a CESI on. I actually submitted a T1-2 ESI as she was mildly stenotic at C7-T1 without posterior epidural fat on T1. Insurance denied it saying I couldn't do a thoracic epidural for her cervical symptoms. instead of wasting my time doing a P2P I unfortunately decided to take my chances at C7-T1. Went super slow and carefully with normal epidurogram. Guess what happened... lady called back with a supposed PDPH. I learned my lesson. Never bend to the insurance bastards

 

[rexed]

- said I didn’t document failed Pt in last 6 months. Patient was in MVC 17 years ago, classic whiplash injury picture, failed multiple rounds of PT, chiro, reiki. Last had been done over a year ago.
- said patient’s symptoms and imaging report were more consistent with radicular pain. Nurse had documented a complaint of tingling in right hand, amongst others. My notes clearly outlined why I felt primary pain was non-radicular. ***** went on to double down that a radiculitis needs to be resolved before we could proceed with MBB. Patient had a C4-5 ILESI (yes, you read that correct) with 2 days of relief at a different center within last 6 months.

You should have a 6 months to a year to proceed, send the patient to PT (again), whether they complete or not, either they complete PT or fail PT, document and you should then have all the boxes checked.

 

[bedrock]

For some reasons I’ve seen a fair amount of thoracic pathology lately. Thoracic radix and thoracic facet OA, in middle age patients on commercial insurance.

Fortunately, almost all of my local commercial companies allow thoracic ESI and RFA.
I’d hate to have tell a patient working to support their family……that they just have to deal with it.

 

[RoloTomassi]

You should have a 6 months to a year to proceed, send the patient to PT (again), whether they complete or not, either they complete PT or fail PT, document and you should then have all the boxes checked.

Yeah and delete anything about tingling

 

[bedrock]

Yeah and delete anything about tingling

Agree. I literally have a list of code words that I include in dictations to remind me that this patient has a particular second pathology that I need to consider after I finish treating the main problem.

So frustrating that we are punished for being good pain physicians who consider multiple pain generators in complex patients.

So all my notes on commercial patients include symptoms and exam findings that only support one diagnosis and one treatment…….until the patient returns and my next note is quite different so I can then treat their second issue which I recognized during the initial consult, but couldn’t clearly state in my first note due to concern of the first procedure being denied.

 

[clubdeac]

Agree. I literally have a list of code words that I include in dictations to remind me that this patient has a particular second pathology that I need to consider after I finish treating the main problem.

So frustrating that we are punished for being good pain physicians who consider multiple pain generators in complex patients.

So all my notes on commercial patients include symptoms and exam findings that only support one diagnosis and one treatment…….until the patient returns and my next note is quite different so I can then treat their second issue which I recognized during the initial consult, but couldn’t clearly state in my first note due to concern of the first procedure being denied.

yeah I agree and it sucks b/c it really does hurt care and diagnosis

 

[rexed]

yeah I agree and it sucks b/c it really does hurt care and diagnosis

It's the world we practice in now....just pretend you're in line for the soup Nazi when preparing your note. Must ask exactly how they want it.....or NO INJECTION FOR YOU!

 

[lobelsteve]

In a similar vein I had a lady with cervical radic that I submitted a CESI on. I actually submitted a T1-2 ESI as she was mildly stenotic at C7-T1 without posterior epidural fat on T1. Insurance denied it saying I couldn't do a thoracic epidural for her cervical symptoms. instead of wasting my time doing a P2P I unfortunately decided to take my chances at C7-T1. Went super slow and carefully with normal epidurogram. Guess what happened... lady called back with a supposed PDPH. I learned my lesson. Never bend to the insurance bastards

Sometimes I cannot see the 1st rib. Winkwink

 

[bedrock]

Sometimes I cannot see the 1st rib. Winkwink

agree with this.

 

[callmeanesthesia]

Sometimes I cannot see the 1st rib. Winkwink

This is the way.

 

[PMROralBoards]

I just had a second mbb denied for excessive mbbs completed in a year. It was their first ever mbb. Pt had 100% relief for a few hours.

 

[Status Sciaticus]

- said I didn’t document failed Pt in last 6 months. Patient was in MVC 17 years ago, classic whiplash injury picture, failed multiple rounds of PT, chiro, reiki. Last had been done over a year ago.
- said patient’s symptoms and imaging report were more consistent with radicular pain. Nurse had documented a complaint of tingling in right hand, amongst others. My notes clearly outlined why I felt primary pain was non-radicular. ***** went on to double down that a radiculitis needs to be resolved before we could proceed with MBB. Patient had a C4-5 ILESI (yes, you read that correct) with 2 days of relief at a different center within last 6 months.

everyone does exericse. so that can count as home exercise program.

In a similar vein I had a lady with cervical radic that I submitted a CESI on. I actually submitted a T1-2 ESI as she was mildly stenotic at C7-T1 without posterior epidural fat on T1. Insurance denied it saying I couldn't do a thoracic epidural for her cervical symptoms. instead of wasting my time doing a P2P I unfortunately decided to take my chances at C7-T1. Went super slow and carefully with normal epidurogram. Guess what happened... lady called back with a supposed PDPH. I learned my lesson. Never bend to the insurance bastards

cant tell what level you did if you take the epidurogram photo after removing the needle.

I just had a second mbb denied for excessive mbbs completed in a year. It was their first ever mbb. Pt had 100% relief for a few hours.

LMAOOO this is a catch 22

 

[geauxg8rs]

I actually do insurance reviews on the side (for a small player insurance company). Don’t shoot me. 90 percent of what i do is inpatient evals. However I do try to review as many pain auths as possible. I approve way more than anyone else, i am the only one board certified/ pain fellowship trained doing these reviews. I think most of the docs are EM or FP and have no clue what we do.

For example,
Last week I ran into an scs trial denial that i was doing for a re evaluation (last step before offer of appeal). It was denied originally because “no percentage of pain relief from trial given” and “no psych evaluation.”

Obviously the original doc who denied is a *****. It’s an auth for a trial, not a perm. And the guidelines that this company uses does not require a psych evaluation for the perm, just an absence of psych disease that isn’t managed. But none of that even applies for the trial auth.

Needless to say i approved it and tried to re educate the nurses and the original doctor.

I did get another doc to curbside consult me on a somewhat similar scenario as the OP. Was a case where the patient had a first mbb with 90 percent relief. The kicker being that this insurance company has their own guidelines, and they consider thoracic mbb/rfa as “experimental” and therefore should have been denied.

So now the doc doing the auth for the repeat mbb was wondering what to do for a second mbb and what about rfa after that?. I said you should approve it, cause how do you tell a patient that the insurance company screwed up and shouldn’t have approved your care. Sorry you got six holes in your back for nothing. You can have one test that you passed but nothing after? Seems problematic. Just approve and eat the cost.

Most of the pain auths that i deny is the request for series of three without any follow up in between. I try to tell the docs when i do the peer to peer what is needed in the note, I think all interactions have gone well except one guy who was adamant that every patient needs at least a series of two for every injection, every time. But he’s the reason why we can’t have nice things.

 

[GlowInTheDark]

I actually do insurance reviews on the side (for a small player insurance company). Don’t shoot me. 90 percent of what i do is inpatient evals. However I do try to review as many pain auths as possible. I approve way more than anyone else, i am the only one board certified/ pain fellowship trained doing these reviews. I think most of the docs are EM or FP and have no clue what we do.

For example,
Last week I ran into an scs trial denial that i was doing for a re evaluation (last step before offer of appeal). It was denied originally because “no percentage of pain relief from trial given” and “no psych evaluation.”

Obviously the original doc who denied is a *****. It’s an auth for a trial, not a perm. And the guidelines that this company uses does not require a psych evaluation for the perm, just an absence of psych disease that isn’t managed. But none of that even applies for the trial auth.

Needless to say i approved it and tried to re educate the nurses and the original doctor.

I did get another doc to curbside consult me on a somewhat similar scenario as the OP. Was a case where the patient had a first mbb with 90 percent relief. The kicker being that this insurance company has their own guidelines, and they consider thoracic mbb/rfa as “experimental” and therefore should have been denied.

So now the doc doing the auth for the repeat mbb was wondering what to do for a second mbb and what about rfa after that?. I said you should approve it, cause how do you tell a patient that the insurance company screwed up and shouldn’t have approved your care. Sorry you got six holes in your back for nothing. You can have one test that you passed but nothing after? Seems problematic. Just approve and eat the cost.

Most of the pain auths that i deny is the request for series of three without any follow up in between. I try to tell the docs when i do the peer to peer what is needed in the note, I think all interactions have gone well except one guy who was adamant that every patient needs at least a series of two for every injection, every time. But he’s the reason why we can’t have nice things.

Your last paragraph is 100% what we need.

A large practice chain in the SE will do two-level bilateral TFESI for all epidurals because they can get it paid and it pays them most. No single level ESI or unilateral TFESI. Always bilateral, always two levels.

 

[runfastnow]

We took our biggest MBB/RF denier and made a macro/dot phrase to specifically answer each of their questions/requirements one by one (so they won't deny and to help our approval team answer their questions on the pre-auth process).

- Basic (XR) and advanced (MRI/CT) maging shows multilevel facet arthropathy at levels which correlates with the patient's axial spinal pain, and this pain is replicated with facet-loading maneuvers.
- Patient presents with >3 months of neck and/or low back pain.
- The patient states the pain is >6/10 at baseline and is worse with activity.
- Indication: The patient has moderate to severe axial chronic neck or low back pain present >3 months that causes functional deficit.
- Patient has failed to respond to noninvasive conservative treatment for >6 weeks including: NSAIDs, physical therapy (PT) and home exercise program (HEP), and chiropractor.
- Patient has an absence of untreated radiculopathy, neurogenic claudication.
- There is no non-facet pathology or radiology studies that explain another pain generator.
- Functional deficit has been obtained by the use of pain scale or disability scale.

If your EMR doesn't support dot phrases try TextExpander - I use for all my op notes, insurance approval blurbs, G2211 justification, EMG reports, etc. Helps cut down on documentation time as much/more than Heidi, etc.

 

[RoloTomassi]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

 

[mygalperin]

I wrote a long rant. It was cathartic. I deleted it because, like diamonds, the internet is forever.

But yes, MBB 1 was approved, 90% relief, they then denied the second for BS reasons beyond comprehension that even the P2P physician couldn’t explain or defend, but still wouldn’t reverse.

Request medical director per to per

 

[1 Up]

I document what I need to document to get the patient the right treatment they need and warrant. More information is not better. The right information, and only the right information, is the way.

 

[ghost800]

I document what I need to document to get the patient the right treatment they need and warrant. More information is not better. The right information, and only the right information, is the way.

Exactly. It’s a shame that it’s come to this but The medical record is becoming quite ridiculous when getting medically reasonable pain procedures approved. Once I decide on a procedure, I work backwards and build my note with only the information they want to hear and nothing else. For example if I want a facet block I don’t document radicular symptoms and vice versa. I always document the “required” physical exam findings when not documenting them will result in a denial. I believe it is good patient care to do what is necessary to provide the medically reasonable treatments. Just my opinion

 

[gaseous_clay]

Please don't.

As a former ER doc, nothing is more infuriating than some random patient being sent in to get something done that is not indicated then make us - ie ER docs - the bad guy for telling the patient to leave.

I didn’t realize that providers actually made recommendations like this to the patient. It’s quite asinine.