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How To Fight A Medical Necessity Denial for Acupuncture (+Appeal Letter Template)


In the world of billing insurance, insurers improperly issue medical necessity denial claims on the basis of treatments being not medically necessary quite frequently. This is especially true in cases where you are billing insurance for acupuncture, medical massage, or chiropractic treatments. Sometimes such denials are a mistake, but all too often, these denials by insurers are intentional and intended to avoid coverage for treatments.

Since these persistent denials exist, it is important for you to understand how to fight a medical necessity denial in order for your patient to receive all of the coverage they are entitled to. Learn more about how to appeal a medical necessity denial claim and the medical appeal letter template you should use for your best chances of revoking the denial.

Is Acupuncture Covered by Insurance?

acupuncture treatments

Healthcare coverage for integrative medicine treatments like acupuncture and massage therapy has come a long way in the United States. Nowadays, it is common practice to complement traditional health care with other modalities like massage and acupuncture. However, not all health insurance plans cover these services, and those that do vary when and what they cover. On top of this, the insurance industry makes the billing process for acupuncture and other holistic treatments difficult and complicated. While some insurance plans will allow these sorts of treatments for a wide variety of medical conditions, others will have more limited plans.

Medicare has special requirements for acupuncture; recently in January 2020, the Centers for Medicare and Medicaid Services (CMS) announced their decision to cover acupuncture for chronic low back pain. Although the update was especially important, as it marks the first time acupuncture codes can be reimbursed by Medicare, the additional requirements made it impossible for most licensed acupuncturists to take advantage of it. 

Unfortunately for holistic practitioners, the insurance industry makes billing for acupuncture and massage complicated with a variety of accompanying regulations and requirements. The majority of covered acupuncture services that need to be billed to insurance fall under four essential acupuncture CPT codes and two medical massage codes. Like other similar therapy-based practices, integrative health practitioners bill their services according to Current Procedural Terminology (CPT) codes. Each code is considered a billable unit used to track what treatments have been administered.

Acupuncture and massage services are always billed in 15-minute increments. For instance, in acupuncture, you will use one code for the initial 15 minutes of service and then a separate code for additional units of time. If you include electronic stimulation in your treatment, your codes will vary as well.

Evaluation and management services, or office visits, may be billed by acupuncture physicians on the initial patient evaluation and periodic follow-up evaluations, typically every 30 days or every sixth visit. However, it is not appropriate to bill these codes every time the patient receives acupuncture treatments, as acupuncture CPT codes 97810, 97813, 97811, and 97814 all include evaluation and management done as part of the overall daily treatment.

Are Chiropractic Treatments Covered by Insurance?

chiropractic treatment

Just as with acupuncture, chiropractic treatments used to be rarely covered by insurance. This has since changed; most health insurance plans now cover chiropractic treatments due to the holistic practice’s positive reputation among many Americans for effective treatments for neck and back pain. In fact, chiropractors see an estimated 35 million people every year in the United States alone. Despite its popularity, insurance may only pay a certain amount of chiropractic treatments or under certain circumstances just as with other holistic disciplines. 

Medicare will cover chiropractic manipulation of the spine for back pain management, but there are additional caveats just as with acupuncture Medicare coverage. To qualify for Medicare reimbursement, the patient must have active back pain and seek out chiropractic care that corrects this problem. Any chiropractic services administered as maintenance or preventative will not be covered, as well as any massage therapy or X-rays. 

What is a Medical Necessity Denial?

When patients have serious medical conditions or illnesses, they may require specific procedures classified as “medically necessary” to treat their condition, known as Based on Medical Necessity (BMN).

Insurers can deny services for the requested treatment by issuing a medical necessity denial when the patient does not appear to meet the necessary criteria to qualify, and therefore cannot be medically certified based on the information provided by the holistic practitioner. When insurance companies deny an insurance claim, they will request a letter of medical necessity from you as a holistic practitioner. This criterion for BMN in regards to your services ranges across insurance companies. For example, one insurance company’s medical necessity criteria may allow acupuncture treatment to be medically necessary for nerve pain, while others may feel it is only medically necessary for back pain.

However, receiving a medical necessity denial from an insurer does not necessarily mean they have the final say. There are steps you can take to contest this decision.

How to Appeal a Medical Necessity Denial

Whenever an insurer issues a medical necessity denial, you can file an appeal with the insurer. Typically, you will need to provide a letter explaining why the denial was improper. It is important to include as much detail and evidence as possible in the appeal letter.

Usually, an appeal must be filed within 180 days of receiving the denial notice. In most states, insurers are required to determine the merits of an appeal to a claim denial within 45 working days due to prompt payment laws.

Acupuncture Letter of Medical Necessity Template

As a medical billing provider specializing in acupuncture, massage therapy, and chiropractic services, Holistic Billing Services has extensive experience dealing with prompt payment laws and medical necessity denials and appeals. If you are planning on filing an appeal, we recommended following this letter template. This free template may be copied onto your practice letterhead and used as a letter of medical necessity when contesting a denied claim!

Before sending in your letter of medical necessity, make a copy of it and any other documents included. Send it in certified with a proof of receipt so you know when it was received by the insurer.

Chiropractic Letter of Medical Necessity Template

If you are fighting a medical necessity denial for chiropractic treatment, then you can also file an appeal with the above-mentioned letter template. When filling out the medical appeal letter template, make sure to mention in detail information on the denied treatment, course of care, and why the treatment is necessary for the patient. 

By filling out this chiropractic letter of medical necessity template, you can help revoke the insurer’s decision! With any medical appeal letters, make sure to make a copy of it along with other documents inside and save it. Send it in certified with a proof of receipt so you know when it was received by the insurer.

Reduce Medical Necessity Denials in Your Holistic Practice With Holistic Billing

Fighting medical necessity denials can be a frustrating experience. Oftentimes, claim denials are due to easily preventable errors, such as missing or invalid authorizations or coding inaccuracies. By ensuring you have an efficient and accurate medical billing process, your holistic practice can help reduce medical necessity denials so you can save the valuable time spent on the denial process on delivering care to your patients!

Implementing an effective billing process is easier said than done, however. By employing a holistic billing provider to handle your billing for you, your practice can focus on what truly matters: delivering care to your patients. Holistic Billing has had years of experience working with holistic practices and helping them enhance their billing processes so they can reach their revenue potential. 

Want to learn more about what an experienced holistic billing provider can do for your acupuncture practice and revenue cycle management? Contact our team of billing and coding experts today for a consultation today!

March 2, 2021
 - by Antonio Arias, MBA, CHBME
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