Medical policies are set at the local payer level, and therefore, health care providers may observe variance in coverage. As such, should a denial occur, it is the responsibility of the health care provider to appeal the claim and address the concern directly with the payer. Specifically, the provider may consider contacting the payer to seek clarification as to exactly why the procedure was denied. Additionally, the provider should request guidance as to specific medical documentation necessary to successfully appeal the claim.

Should a denial occur because of the question of medical necessity relative to the implant or follow-up procedure, the provider can use the following sample appeal letter. Please note that the following letter is only a SAMPLE, and it is the responsibility of the health care provider to determine the necessary content.

Download Sample Payer Appeal Letter (PDF)

Physician

Ambulatory Surgery Center (ASC)

Hospital Outpatient

Hospital Inpatient

¹American Medical Association. Current Procedural Terminology (CPT) 2007. Professional Edition. Chicago, IL 2007. Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a registered trademark of the American Medical Association.

²Centers for Medicare and Medicaid Services. Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgery Center Payment System Calendar Year 2008 Payment Rates; Final Rule. In: Federal Register. (codified at 42 §410, §485, et al). Thursday, November 1, 2007.

³Ingenix. ICD-9-CM Expert for Hospitals - Volume 1, 2 & 3, 6th Edition. August 2007.

⁴Centers for Medicare and Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule. In: Federal Register. (codified at 42 §410, §489, et al.) Friday, August 3, 2007.

A revision to the AMA CPT codes/guidelines is in process.

W hen submitting claims for services that require a CPT code, providers must report the most specific and appropriate code available. Occasionally, a CPT code is not available for reporting, such as for the followup service for an implantable patient-activated cardiac event recorder with 24-hour attended monitoring capability. Providers should assign the appropriate unlisted procedure code when a more appropriate code is not available. When reporting 93799, verify the preferred process with the local Medicare contractor, as claims processing instructions may vary. The following is a suggested approach when submitting an unlisted code for payment.

• Enter in Item 19 of the CMS-1500 claim form the concise description of the unlisted procedure code.
• Use an ICD-9-CM diagnosis code to accurately document the condition or reason responsible for the unlisted procedure as documented in the medical record.
• Submit the operative report with the claim and highlight the portion that identifies the procedure associated with the unlisted code.
• Submit a letter written by the physician describing the procedure and medical necessity. Specifically include in the letter a comment indicating a specific CPT code does not exist for monitoring an internal cardiac event recorder with 24-hour attended monitoring capability. Suggest to the Medicare contractor a review of the 93268 - 93272 CPT code series which represent monitoring of an external event recorder as a comparable code description. Lastly, structure the letter similar to the "Sample Appeal Letter" in Section 5 of this document. The contents of this letter will be helpful in describing the details of the implant procedure and follow-up services.

Medicare coverage varies by local contractor; however, most contractors do cover this technology for patients with a clinical indication of syncope. Occasionally, a diagnosis of palpitations is also covered by the Medicare local contractor. However, it is the responsibility of the health care provider to confer with the respective carrier / fiscal intermediary to determine coverage eligibility.

The Medicare local coverage policies provide a list of covered diagnosis codes that describe patients at risk of arrhythmia. The following list is being provided because this technology is also FDA indicated for patients at risk of arrhythmia. However, it is important to note that Medicare coverage may vary from the FDA indication. As such, it is the responsibility of the health care provider to determine the most appropriate clinical diagnosis for each patient and confer with the respective carrier / fiscal intermediary to determine coverage eligibility.

Ensure that the physician clearly documents the patient's diagnosis that indicates the patient for the device. Specific details of the procedure performed, total procedure time, and notes regarding any unique circumstances (eg, discontinued procedure, increased follow-up frequency) should also be documented.

Ensure that providers (hospital and physician) report accurate charges for the procedure and device costs.

File the claim in a timely manner based on payer requirements subsequent to performance of the procedure.

Consult with the respective Medicare carrier, fiscal intermediary, or other payer to clarify coding, coverage, and payment questions/concerns, as the payers are the official authority over these matters.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have acknowledged that the "diagnostic evaluation of syncope is determined by many clinical factors." Therefore, the ACC and AHA have established a set of indications to assist physicians when assessing patient symptoms. The indications for ambulatory electrocardiography (AECG) for Class I, IIb and III patients are listed below.

CLASS I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

• Patients with unexplained syncope, near syncope, or episodic dizziness in whom the cause is not obvious
• Patients with unexplained recurrent palpitation

CLASS IIb: Usefulness/efficacy is less well established by evidence/ opinion.

• Patients with episodic shortness of breath, chest pain, or fatigue that is not otherwise explained
• Patients with neurological events when transient atrial fibrillation or flutter is suspected
• Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in whom a probable cause other than an arrhythmia has been identified but in whom symptoms persist despite treatment of this other cause

CLASS III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful effective and in some cases may be harmful

• Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in whom other causes have been identified by history, physical examination, or laboratory tests
• Patients with cerebrovascular accidents, without other evidence of arrhythmia

5.2.3. Ambulatory Electrocardiography Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

• Ambulatory ECG is indicated when there is a need to clarify the diagnosis by detecting arrhythmias, QT interval changes, T-wave alternans (TWA), or ST changes, to evaluate risk, or to judge therapy. (Level of Evidence: A)
• Event monitors are indicated when symptoms are sporadic to establish whether or not they are caused by transient arrhythmias. (Level of Evidence: B)
• Implantable recorders are useful in patients with sporadic symptoms suspected to be related to arrhythmias such as syncope when a symptomrhythm correlation cannot be established by conventional diagnostic techniques. (Level of Evidence: B)