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This is an CT scan code to scan the heart. 75571-26. The 26 modifier is the professional component of the code to interpret the imaging results. The technical component is for acquiring the images. Insurance companies are notorious for saying anything they don't cover is "experimental" when they don't want to pay for it.
Ah, I see. I was looking for the CPT code using the 26 as part of the code.
Medicare does not cover the procedure. The patient should have been told that.
Hospital was paid, just radiology got denied. Will call secondary insurance if dad gets another bill and will find out if eob got any power
Medicare does not cover coronary artery calcium scoring as a stand alone procedure, and if it was done as part of another radiology procedure it is bundled with that procedure for one fee. The medigap policy will not pay anything if Medicare does not cover it.
If the Blue Cross plan is not a medigap but commercial insurance it may also be a noncovered procedure for that company, too.
This particular plan requires a prior authorization for it. Other plans may differ.
Medicare does not cover coronary artery calcium scoring as a stand alone procedure, and if it was done as part of another radiology procedure it is bundled with that procedure for one fee. The medigap policy will not pay anything if Medicare does not cover it.
If the Blue Cross plan is not a medigap but commercial insurance it may also be a noncovered procedure for that company, too.
This particular plan requires a prior authorization for it. Other plans may differ.
Yes medicare denied it because it's experimental but so did secondary who is contracted with them. The procedure code that i see is only what i posted which is on EOB
12/16/19 Radiology
7557126 175.00 0.00 0.00 0.00 0.00 0.00 1
Claim Totals: 175.00 0.00 0.00 0.00 0.00
Notes
1 The service or item is identified in the Health Plan Medical Policy as investigational or experimental and therefore is not
covered. Upon request, the scientific or clinical judgment used for the determination will be provided to you, free of charge.
Your request should be submitted to us at the address or telephone number indicated on the front of this form
So while i understand that if medicare denies they can bill, how does that work when secondary in network insurance denies it as well?
As other posters have said, secondary medigaps do not have "networks," they follow Medicare (which does not have a network) and pay a portion (or all) of the remaining 20% of the Medicare charges.
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An earlier post indicated this was for a calcium coronary scan. Here is an article from 2013 that discusses the medical benefits of this scan.
"The coronary calcium scan has been around for about 15 years, but only recently has a consensus emerged that it is the best tool for evaluating heart attack risk."
"Although a coronary calcium scan only costs $100, not all insurance plans cover it; Medicare covers it in some states, but not in New York."
A long article below indicates which states pay and which states do not pay for the coronary calcium scan and their policies.
"In all cases, the test is never covered for screening, i.e., in the absence of signs, symptoms or disease."
Here are some of the rules for payment in states that will pay for it:
"The test will be considered not medically necessary if the anticipated results are not expected to provide new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing."
"The test will be considered not medically necessary if pretest evaluation indicates that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention."
"The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.)"
Bottom line: If there are medical indications, then the scan might be covered by Medicare or other insiurance, but it varies state to state.
The article below lists which states pay, which states do not, and which states don't have a specific policy in this regard.
Can you explain what this "preferred provider" is all about? I do know people have mistakenly assumed a medigap plan through a particular insurance company means their provider directory for individual plans also applied. A neighbor in my community had been picking their medical providers based on what was in-network and who was a preferred provider from the individual non medciare provider directory of that insurance company. That lead to all sorts of issues.
The "preferred provider" depends on the area where you live. For pharmacy, they may have Walgreen & not CVS or Kroger or Target. They may have another option for pharmacy by mail so that they deliver most items to your door. You will still need a local pharmacy for items you need now. For medical can start with hospital, could be the one closest. The doctor should be part of the hospital. For specialist from EMT to anesthesia doctors can be different.
You can use Medicare.gov to see who the "preferred providers" in your area are. Also depends if you have Medicare Supplement or Medicare Advantage plan. The listing in the Medicare.gov should be the same as the one from the insurance company. Also, you can ask at Walgreen if they participate as a preferred provider with that insurance company.
The "preferred provider" depends on the area where you live. For pharmacy, they may have Walgreen & not CVS or Kroger or Target. They may have another option for pharmacy by mail so that they deliver most items to your door. You will still need a local pharmacy for items you need now. For medical can start with hospital, could be the one closest. The doctor should be part of the hospital. For specialist from EMT to anesthesia doctors can be different.
You can use Medicare.gov to see who the "preferred providers" in your area are. Also depends if you have Medicare Supplement or Medicare Advantage plan. The listing in the Medicare.gov should be the same as the one from the insurance company. Also, you can ask at Walgreen if they participate as a preferred provider with that insurance company.
The OP has a Medigap plan. There should be no providers to select specific to that insurance company as it's based only on Medicare coverage. If covered through medicare, the plan picks up where medicare cuts off. If medicare does not cover that procedure or provider, the plan won't cover it as well. So if medicare does not cover a procedure, it doesn't matter one bit if the provider is some preferred provider with that insurance company, the Medigap plan will not cover it as well.
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