Facet Joint Block appeal; need help (UNHC)

[Texas-T]

I love insurance companies....

My old insurance company (United Healthcare) who denied my ADR, is refusing to pay for my facet joint block. They are stating that I must prove that it improved or resolved the condition. The problem is, I don't have painful facet joints, as many of you know - the test is both a) diagnostic to determine if there is a problem with your joints and b) helps the joint's if there is a problem. So by their standard, they will only pay if the test worked.

I've never done an appeal and this is one of several service's that I must appeal to UNHC. As soon as I changed providers they started denying services.... so I need a quick education in the process.

Also, they want me to provide my medical record to prove that I needed the test. If I provide this record can they use information found within to deny more services?

I would truly appreciate any advice,

[Kim]

Tricia
I would suggest getting a statement from Bitans office stating why the facet block injection was needed in the first place. That would go a long way toward getting past the denial.
Also look carefully at the diagnosis on the paperwork that was submitted to UHC with this. Things are denied frequently due to the fact that the computer kicks it out because the diagnosis does not "gel" with what is acceptable for them according to that test.
Sometimes just adding a diagnosis and refiling the claim will get it approved.
I had a problem with an MRI last year getting paid due to the fact that the billing clerk had not put all of the diagnosis on my claim. The one she had put on there did not pertain to the MRI so when we got that straightened out it was approved.
No they should not be able to use the records to deny other claims. In fact you can make a statement that you give them permission to view the info for the purpose of this appeal only.
Hope this helps