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Home > Archive > Heartburn Support > August 2006 > Stretta not a valid procedure?
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Stretta not a valid procedure?
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| I was scheduled for the Stretta procedure this week, but got a call
from the GI doctor today informing me that United Healthcare would not
cover the Stretta procedure, as they said it was removed from THE
comprehensive book of medical procedures in December 2004 and therefore
not a valid procedure. Can anyone offer insight?
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| Howard McCollister 2006-08-15, 8:24 am |
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"tj1" <tjohnson01@gmail.com> wrote in message
news:1155628272.792198.195410@i3g2000cwc.googlegroups.com...
>I was scheduled for the Stretta procedure this week, but got a call
> from the GI doctor today informing me that United Healthcare would not
> cover the Stretta procedure, as they said it was removed from THE
> comprehensive book of medical procedures in December 2004 and therefore
> not a valid procedure. Can anyone offer insight?
>
Just insurance company bullshit. I don't even know what THE comprehensive
book of medical procedures is - never heard of it.
The Stretta procedure can be very successful if the patients are selected
properly IMHO. Insurance companies are always resistant to expensive
treatments that make is easier for a larger number of patients to address
extremely common problems like GERD - it costs them more money.
Consequently, many insurance companies have labeled the Stretta procedure
"investigational" and won't pay for it.
HMc
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| Thanks for the response Howard. I called United today, and was told
there is a master book, not just unique to United, that assigns a
procedure code to every valid medical procedure. Since the Stretta was
removed (according to them) from this book in 12/04, they consider it
invalid and won't cover it. Bottom line: they ain't payin... My
doctor has 2 other patients who had to cancel their Stretta
appointment this month, as they also had United Healthcare. He said he
would call United on our behalf and see what can be done, and to give
him a call in 2 weeks. Strangely enough, they will cover the
fundoplication, which I'm not interested in. Or the other option would
be to pay for the Stretta out of pocket, which they quoted $4200
ballpark.. I could try to switch providers, but don't know if I can
get coverage with a pre-existing condition.
Howard McCollister wrote:
> "tj1" <tjohnson01@gmail.com> wrote in message
> news:1155628272.792198.195410@i3g2000cwc.googlegroups.com...
>
> Just insurance company bullshit. I don't even know what THE comprehensive
> book of medical procedures is - never heard of it.
>
> The Stretta procedure can be very successful if the patients are selected
> properly IMHO. Insurance companies are always resistant to expensive
> treatments that make is easier for a larger number of patients to address
> extremely common problems like GERD - it costs them more money.
> Consequently, many insurance companies have labeled the Stretta procedure
> "investigational" and won't pay for it.
>
> HMc
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| Howard McCollister 2006-08-16, 4:23 pm |
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"tj1" <tjohnson01@gmail.com> wrote in message
news:1155708920.556944.87050@i3g2000cwc.googlegroups.com...
> Thanks for the response Howard. I called United today, and was told
> there is a master book, not just unique to United, that assigns a
> procedure code to every valid medical procedure. Since the Stretta was
> removed (according to them) from this book in 12/04, they consider it
> invalid and won't cover it. Bottom line: they ain't payin... My
> doctor has 2 other patients who had to cancel their Stretta
> appointment this month, as they also had United Healthcare. He said he
> would call United on our behalf and see what can be done, and to give
> him a call in 2 weeks. Strangely enough, they will cover the
> fundoplication, which I'm not interested in. Or the other option would
> be to pay for the Stretta out of pocket, which they quoted $4200
> ballpark.. I could try to switch providers, but don't know if I can
> get coverage with a pre-existing condition.
>
Ah..I understand now. The book you (they) are referring to is Current
Procedural Terminology (CPT). This manual comes out yearly and assigns codes
to all current (and valid) surgical and medical procedures.
As I said, the word you and your doctor are getting from United is bullshit.
The appropriate code for Stretta, from page 181 of the 2006 CPT Manual, is
43257, which says:
" 43257 -- [Upper gastrointestinal endoscopy] with delivery of thermal
energy to the muscle of the lower esophageal sphincter and/or gastric
cardia, for treatment of gastroesophageal reflux disease."
THAT is the Stretta procedure, and it was *added* to the CPT manual in 2004
after the efficacy of the Stretta procedure was demonstrated in at least two
extensive, peer-reviewed, randomized prospective studies WITH sham
crossover.
Like many or most procedures these days, physicians pre-certify patients to
get pre-approval from the insurance company to be sure that they will pay
for the procedure. It is conceivable that your doctor, or his coders, are
not submitting the proper code to United Healthcare. Ask your doctor if the
code he submitted is 43257. IIRC there is also another code that is
typically submitted along with 43257 for "radiofrequency nerve ablation",
addressing the other aspect of the Stretta procedure that ablates afferent
nerve fibers to the LES to prevent transient inappropriate LES relaxation
(another significant cause of intractable reflux).
Check it out with your doctor. And if you talk to your insurance company
again, ask them about CPT code 43257.
HMc
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| Thank you for your insightful advice Howard. I really appreciate it.
I called United again, asked them about that procedure number, and was
told they would cover 90% with no authorization required. Confused, I
called my doctors office to see if there had been some mistake. The
Dr's assistant said they had been down this road before. Even though
customer service said the procedure was covered, the claims department
would reject the reimbursal on the grounds that the procedure was
invalid. Anyway, Dr. Goff is going to call United personally to see
what can be done, and I should get an update from them sometime next
week. Thanks again.
Howard McCollister wrote:
> "tj1" <tjohnson01@gmail.com> wrote in message
> news:1155708920.556944.87050@i3g2000cwc.googlegroups.com...
>
>
> Ah..I understand now. The book you (they) are referring to is Current
> Procedural Terminology (CPT). This manual comes out yearly and assigns codes
> to all current (and valid) surgical and medical procedures.
>
> As I said, the word you and your doctor are getting from United is bullshit.
> The appropriate code for Stretta, from page 181 of the 2006 CPT Manual, is
> 43257, which says:
>
> " 43257 -- [Upper gastrointestinal endoscopy] with delivery of thermal
> energy to the muscle of the lower esophageal sphincter and/or gastric
> cardia, for treatment of gastroesophageal reflux disease."
>
> THAT is the Stretta procedure, and it was *added* to the CPT manual in 2004
> after the efficacy of the Stretta procedure was demonstrated in at least two
> extensive, peer-reviewed, randomized prospective studies WITH sham
> crossover.
>
> Like many or most procedures these days, physicians pre-certify patients to
> get pre-approval from the insurance company to be sure that they will pay
> for the procedure. It is conceivable that your doctor, or his coders, are
> not submitting the proper code to United Healthcare. Ask your doctor if the
> code he submitted is 43257. IIRC there is also another code that is
> typically submitted along with 43257 for "radiofrequency nerve ablation",
> addressing the other aspect of the Stretta procedure that ablates afferent
> nerve fibers to the LES to prevent transient inappropriate LES relaxation
> (another significant cause of intractable reflux).
>
> Check it out with your doctor. And if you talk to your insurance company
> again, ask them about CPT code 43257.
>
> HMc
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| Howard McCollister 2006-08-18, 4:23 pm |
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"tj1" <tjohnson01@gmail.com> wrote in message
news:1155888840.290666.322520@p79g2000cwp.googlegroups.com...
> Thank you for your insightful advice Howard. I really appreciate it.
> I called United again, asked them about that procedure number, and was
> told they would cover 90% with no authorization required. Confused, I
> called my doctors office to see if there had been some mistake. The
> Dr's assistant said they had been down this road before. Even though
> customer service said the procedure was covered, the claims department
> would reject the reimbursal on the grounds that the procedure was
> invalid. Anyway, Dr. Goff is going to call United personally to see
> what can be done, and I should get an update from them sometime next
> week. Thanks again.
>
I don't know how it works in your state, or with United, but here, for the
majority of our third party payors, we submit the procedure codes to the
insurance company along with the diagnostic workup and they have 30 days to
either pre-approve the procedure or deny it. Their agreement to pay for the
Stretta is determined before we ever go to do the procedure.
Note that this procedure can become substantially more muddled if the
patient is on Medicare. In many cases, Medicare won't pre-approve some
procedures. In those cases, we require that the patient agree to pay up
front, then we reimburse them if Medicare does agree to pay after we submit
the bill.
If you are not Medicare, then it seems to me that your doctor should be able
to submit your procedure to United Healthcare for pre-approval. Note that
this is all based on my experience. Let me add the disclaimer that these
kinds of insurance matters vary state-by-state and company-by-company, and
I'm absolutely no expert in insurance billing procedures.
You might consider calling Curon Medical and running this by them - they
have reimbursement specialists that deal with these kinds of questions and
they may be able to shed some light. Curon Toll Free Customer Service Line:
(877) 734-2873
HMc
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