Insurance Clarification / CPT Code Regarding Stomaphyx

(deactivated member)
on 9/27/07 12:20 pm
I have just been denied the stomaphyx procedure by my insurance.  They are saying it was denied because it is an investigational procedure.  The person I spoke with referred to the fact that the surgeon's office used a miscellaneous CPT (current procedural terminology) code for the request for precertification.  I am wondering if anyone has been approved through insurance for the stomaphyx procedure and if they know what CPT code was used to request the precertification/approval?   I am wondering if a CPT code even exists for it yet, but the procedure would still have to fall under something for whoever has had it done.  I now have to appeal and any help/insight would be appreciated.  Trying to get ahold of someone at Endogastric Solutions has not been easy.  I may contact the attorney posting on this forum, but I do not see the stomaphyx procedure mentioned on his website.
akvickery
on 9/29/07 4:07 pm - Bristol, IN
I am at home and do not have my cpt book here, but I will tell you that if this is a newer procedure, which from what I am reading online is the case, then there may not be an actual CPT code available and the precert department would have to sue the miscellaneous code.   You may try getting your PCP to write a letter of medical necessity and submit that to the insurance co.  - Don't be so quick to APPEAL as you only get 2 formal appeals - instead, submit "inquiries" to the insurance co -  this is basically asking them to explain themselves to you. I am a Certified Professional Coder, and an insurance biller, I will be happy to assist you if you'd like to send me a message here. Best of luck, Lori
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