Florida Medicare has a local medical policy stating, “It has been determined that these procedures are investigational, as current domestic medical literature provides inadequate data to permit scientific conclusions regarding improved health outcomes.” While Medicare has a policy stating these procedures are investigational, they are seeking literature supporting the efficacy of this technology in conjunction with the primary surgical procedures. Medicare has an assigned RVU and payment schedule linked to CPT code 20985 thus the AR staff should create an effective appeal strategy.

Action Steps:
1) Review diagnosis codes to ensure medical necessity of the procedures

2) Ensure the surgeon(s) are documenting the additional work of the service and documenting intra-operative and post procedure findings based on the image guidance

3) Appeal to the payors with the operative note documenting the medical necessity of why the procedure required the technology and findings.

4) Submit peer reviewed literature with the appeal

5) Request the patient sign an ABN in the event Medicare continues to deny for medical necessity if the surgeon expects reimbursement in light of a Medicare denial. (Medicare is denying for medical necessity not as a bundled service, thus the financial liability can be transferred to the patient with an ABN on file.)