RFA denial letter by pain physician

[TIVAndy]

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just wanted to share somewhat sad/funny story..

i have a WC patient who passed 2 mbb now waiting for RFA.
received a denial letter with utilization review done by another physician

it said lumbar RFA "not indicated for chronic lumbar pain"

in my mind i was thinking - this can't be a pain guy. let me rip them apart by saying that the reviewer is not boarded in pain..

lo and behold, the guy is actually board cert - anesthesiology/ pain

I looked his practice up.. he offers RFA in his practice.

At this point I am thinking - why would you say something in a letter that would affect another patients' life that you don't believe it's true? if the guy truly believed in what he said i would understand it, but to say it doesn't work for chronic lumbar pain and then offer it in his practice? this is nothing more than whoring out to insurance company for petty money.

i took pictures to expose him (maybe) but decided not to publicly shame him.

just a rant. have a good sunday guys.

 

[geauxg8rs]

wc approved the two mbbs and not the rfa? That is like basically insurance assault. I do insurance reviews and have brought this up to the company. If we approve the mbbs then the RFA should be approved unless they didn’t get the required percent pain relief. Otherwise we are basically approving two procedures knowing they won’t get the third. That is just plain wrong putting someone through this knowing you wouldn’t approve the third one. Criminal

 

[TIVAndy]

wc approved the two mbbs and not the rfa? That is like basically insurance assault. I do insurance reviews and have brought this up to the company. If we approve the mbbs then the RFA should be approved unless they didn’t get the required percent pain relief. Otherwise we are basically approving two procedures knowing they won’t get the third. That is just plain wrong putting someone through this knowing you wouldn’t approve the third one. Criminal

yes wrong in many ways

 

[Laryngospasm]

The last few years there has been a noticeable change in denials etc. very disheartening and makes it difficult to take care of patients. A pain physician denying rfa while offering it in their own practice just shows how far things have deteriorated.

 

[Agast]

That’s funny, since you have to “fail at least six weeks of conservative treatment in the last three months” to do most interventional pain procedures. Can’t have acute pain, can’t be too chronic?

 

[mille125]

Definitely terrible. I dont see WC patients for this reason.

WC has its own criteria that doesn't make sense.

I had a commercial patient that had a successful SCS trial and we had to really fight for the permanent. Makes no sense.

 

[Ducttape]

it may be the diagnosis you utilized, and he is following WC guidelines by the letter.

does the auth request use "chronic lumbar pain" or something more specific such as facet arthropathy, or lumbar spondylosis without radiculopathy or myelopathy?

 

[Agast]

it may be the diagnosis you utilized, and he is following WC guidelines by the letter.

does the auth request use "chronic lumbar pain" or something more specific such as facet arthropathy, or lumbar spondylosis without radiculopathy or myelopathy?

Yeah, in Texas you have to use the compensible injury diagnosis

Lumbar strain - do an epidural
Lumbar strain - do medial branch blocks

Very annoying

 

[mille125]

Yeah, in Texas you have to use the compensible injury diagnosis

Lumbar strain - do an epidural
Lumbar strain - do medial branch blocks

Very annoying

That sounds crazy. Definitely not for me.

 

[SSdoc33]

it would love to see him publicly shamed. but, you have to be sure he isnt sitting on a technicality like percentage of pain relief or submission of the incorrect diagnosis.

 

[Dr. Ice]

I have previously had wc deny rfa stating that facet disease could not possibly be work related because by its very nature is chronic and therefore not related to work injury. Don’t know why they approved the blocks though

 

[Ducttape]

facet syndrome could be an appropriate diagnosis in that case

or whiplash injury + spondylosis (lumbar/cervical)

 

[callmeanesthesia]

All of this is by design. Any delay saves them money.

Don’t bother with peer to peer. Schedule patient for follow up, document in your note why denial is bs and make sure you’re hitting all the WC criteria. Bill 99214, WC PR2, and G2211. Tell patient to submit IMR if denied again. Most of the time that works.

 

[geauxg8rs]

Does patient have a WC lawyer? It will help with approvals and might help come settlement time?

 

[TIVAndy]

That’s funny, since you have to “fail at least six weeks of conservative treatment in the last three months” to do most interventional pain procedures. Can’t have acute pain, can’t be too chronic?

subacute pain? 🙂

 

[TIVAndy]

Yeah, in Texas you have to use the compensible injury diagnosis

Lumbar strain - do an epidural
Lumbar strain - do medial branch blocks

Very annoying

yes lumbar sprain for me and facet syndrome

 

[TIVAndy]

All of this is by design. Any delay saves them money.

Don’t bother with peer to peer. Schedule patient for follow up, document in your note why denial is bs and make sure you’re hitting all the WC criteria. Bill 99214, WC PR2, and G2211. Tell patient to submit IMR if denied again. Most of the time that works.

i think u are using california lingo. we have different terminology (in fact most states is different and nuanced) but eventually most will allow - just takes anywhere between few months to few years (yes that long)

 

[TIVAndy]

Does patient have a WC lawyer? It will help with approvals and might help come settlement time?

yep

 

[callmeanesthesia]

i think u are using california lingo. we have different terminology (in fact most states is different and nuanced) but eventually most will allow - just takes anywhere between few months to few years (yes that long)

Yes, WC California. Lots of paperwork for crap rates.

 

[hyperalgesia]

just wanted to share somewhat sad/funny story..

i have a WC patient who passed 2 mbb now waiting for RFA.
received a denial letter with utilization review done by another physician

it said lumbar RFA "not indicated for chronic lumbar pain"

in my mind i was thinking - this can't be a pain guy. let me rip them apart by saying that the reviewer is not boarded in pain..

lo and behold, the guy is actually board cert - anesthesiology/ pain

I looked his practice up.. he offers RFA in his practice.

At this point I am thinking - why would you say something in a letter that would affect another patients' life that you don't believe it's true? if the guy truly believed in what he said i would understand it, but to say it doesn't work for chronic lumbar pain and then offer it in his practice? this is nothing more than whoring out to insurance company for petty money.

i took pictures to expose him (maybe) but decided not to publicly shame him.

just a rant. have a good sunday guys.

No one will ever appreciate the time you spend with these peer to peers.

 

[BoardingDoc]

No one will ever appreciate the time you spend with these peer to peers.

I've just stopped doing P2Ps completely. Took me less than a year out of fellowship to get there. I had two show up in my bucket last week. I tried calling each one 6 separate times over the course of a couple of hours. Spent a grand total of maybe 30 minutes on hold only to be sent to a voicemail every time. I told my secretary from now on, she can reply to any P2P request that the company can either approve or deny my request in writing and that I will respond in kind.

 

[MitchLevi]

Reviewer may be saying the pain is chronic and not related to the injury, but I would fight that because financially (not sure your state's rules) a WC RFA is a great paying procedure for you, and if you do it and the pt fails to get relief you end their case after putting them MMI and then it is back to work under full duty with no FCE/PIR. WC should be happy you offered this.

 

[pinstriped1992]

I've just stopped doing P2Ps completely. Took me less than a year out of fellowship to get there. I had two show up in my bucket last week. I tried calling each one 6 separate times over the course of a couple of hours. Spent a grand total of maybe 30 minutes on hold only to be sent to a voicemail every time. I told my secretary from now on, she can reply to any P2P request that the company can either approve or deny my request in writing and that I will respond in kind.

How has this worked for you in terms of eventually getting approvals? What's your typical turnaround time... Our front desk spends a lot of time on this coordination so I like this idea.

 

[callmeanesthesia]

How has this worked for you in terms of eventually getting approvals? What's your typical turnaround time... Our front desk spends a lot of time on this coordination so I like this idea.

I don’t do them except in unusual circumstances. Get denial, schedule patient for f/u, document and rebut reason for denial and resubmit, tell patient to submit for IMR if denied (this is CA - I was told the process may be different elsewhere)

 

[BoardingDoc]

How has this worked for you in terms of eventually getting approvals? What's your typical turnaround time... Our front desk spends a lot of time on this coordination so I like this idea.

So far I haven't had a single procedure denied by going this route. Sometimes they don't even deny it when my secretary says I'm not doing a P2P. They just approve it.

In cases where they do deny it, I read the reason why, add documentation and resubmit. Has worked every time so far. Depending on insurance it certainly might add a few days to a week to the process but that isn't my problem and I simply tell the patient the truth if they complain: "your insurance is doing what they do best, delaying or denying care. I'm putting everything they ask for in writing so they have less of a leg to stand on, but there's only so much I can do with these a**holes"