Dynesys® Dynamic Stabilization System - FAQs
1. How do I know if a service or procedure will be covered by the patient's insurance carrier?
Answer: Coverage policies vary by payer. Payers may make medical policies available to providers to articulate which procedures are covered. Contact the payer directly with questions regarding medical policies or guidelines for dynamic stabilization devices.
2. Can a health care provider request a prior-authorization from a payer with an existing non-coverage policy for the treatment?
Answer: Yes - the health care provider can request a prior-authorization for treatments that fall under a non-coverage medical policy for a payer. Please note that the chance of denial is higher for these services, and the health care provider must place a greater emphasis on articulating why the procedure is medically reasonable and necessary for the specific patient they intend to treat.
3. Are there any options for getting the Dynesys System approved for patients with payers that have published non-coverage policies for dynamic stabilization?
Answer: The Dynesys System is indicated only for use as an adjunct to fusion. It may be possible to obtain coverage on a case-by-case basis from insurers that have established non-coverage policies. The chance of prior-authorization denial is higher for these services, and the health care professional must place a greater emphasis on articulating why the procedure is medically reasonable and necessary for the specific patient they intend to treat. (See Appendix B: Sample Letter of Medical Necessity)
Non-coverage policies for treatment with dynamic stabilization devices may not apply to those individuals covered by health plans under the Federal Employee Program (FEP) or self-funded plans that come under the Employee Retirement Income Security Act (ERISA). It is recommended that the health care provider and/or the patient contact the FEP or the employer and/or the third-party administrator for guidelines and instructions.
4. Will Medicare give prior-authorization for spine surgery?
Answer: The Medicare program does not give prior-authorization, prior approval or a predetermination of beneifts for any services. General coverage guidelines for many services can be found using the Medicare Coverage Database. The Medicare coverage guidelines are posted on the CMS web site.
5. Does the physician have to demonstrate medical necessity when appealing a denied claim or service?
Answer: Yes - it is strongly recommended that the physician demonstrate medical necessity when requesting an appeal of a denied claim or service. To establish medical necessity, the physician must clearly describe the condition(s) that justify why the medical procedure should be provided. The more complete the detailed description provided by the physician increases the probability of overturning the denied claim or service.
6. If I get a prior-authorization approval, will I get paid for the procedure?
Answer: Prior-authorization means that the insurer has given approval for a patient to receive a treatment, test or surgical procedure before it has actually occurred. The intent is to determine medical necessity and appropriateness of the proposed treatment and the appropriate treatment setting. A prior-authorization approval does not guarantee payment.
7. What is the patient's financial responsibility for a spinal surgical procedure?
Answer: In order to determine the patient's financial responsibilities, contact the patient's insurance plan by calling the number on the patient's insurance card to verify co-payment, deductible, and any other out-of-pocket expenses.
8. Why do I need to know if the patient has out-of-network benefits?
Answer: It is important to know if a patient has out-of-network benefits because if the treating physician is an out-of-network provider and the plan does not allow out-of-network provider services, the services may be denied. In such cases the patient will need to find an in-network provider to perform the services.
9. Can I appeal a denied prior-authorization request?
Answer: Yes, a denial for a prior-authorization request can be appealed. It is important to address the reason for the denial in the prior-authorization appeal letter. The reason for the denial is found in the prior-authorization denial letter. Contact the payer for specific appeal instructions.
10. How do I code for the Dynesys System as an adjunct to fusion with autogenous graft?
Answer: Health care providers should select the procedure code(s) they feel most appropriately describe the services provided when using the device. Responsibility for correct coding lies with the service provider. The Zimmer Reimbursement Hotline, which provides live coding information via dedicated reimbursement specialists, is available 9 am to 8 pm eastern, Monday through Friday at (866) 946-0444. Zimmer also offers a Dynesys ® Dynamic Stabilization System Reimbursement and Coding Reference Guide at www.reimbursement.zimmer.com.
11. How do I know the reason why a claim has been denied?
Answer: The claims denial letter contains the reason(s) for the denial as well as instructions for the appeal. The denial code(s) can be found on the explanation of benefits. The explanation of benefits does not contain instructions for appeal. Contact the payer for specific instructions to appeal the claim.
12. I have exhausted all of my options for appealing a denial. Are there any other steps available to continue the process of obtaining an approval for coverage?
Answer: There are state-specific and payer-specific guidelines that must be followed to elevate the appeal to a higher level. The type of insurance determines whether federal or state laws apply to the appeal process. If the plan is self-funded through an employer group then the Employee Retirement and Income Security Act (ERISA) applies. If it is commercial insurance, state law applies and the state Division of Insurance (DOI) has jurisdiction.
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Reimbursement Kit Chapters
Overview
Payer Coverage
Insurance
Verification Process
Prior
Authorization Process
Coding Guidance
Appeals
Sample Letters
Disclaimer
