I have seen all kinds of denials but one for test socket?
The service for procedure codes L5620(test socket), Preservice (??),
was not approved for the member because the member’s clinical
circumstances (she is TTA for quite a few years and had very outdated
TTA prosthesis that was built as K3) do not meet one or more BCBSIL
Medical Policy criteria that relate to the efficacy of the service
itself and/or the medical necessity of the service.
The requested now TEST PROSTHESIS and all codes would not be
considered medically necessary per records provided and per plan
criteria (MD clinical provided, AMP PRO K2 provided, all prosthetist
notes provided, long term prosthetic user) does not support the
medical need for the requested prosthesis as not being covered for
TEST PROSTHESIS at this level of ambulatory status.
This actually was final appeal determination response as first time
they bounced based on lack of K level determination. How test socket
relayed into test prosthesis beats me.
Making all aware.
I. Lesko, LPO