PROCEDURE DENIAL PLAYBOOKS

How to appeal high-dollar procedure denials.

The procedures worth the most and denied the most — why each one gets denied, and what actually overturns it. Find your procedure.

Dermatology

Mohs Surgery
CPT 17311-17315 (Mohs), often with repair 13100-14302 / 15004-15261
Lesion Destruction (Malignant / Premalignant)
CPT 17000-17004 (premalignant, e.g. AKs), 17110-17111 (benign), 17260-17286 (malignant)

Dermatology / Pathology

Skin Biopsy & Pathology (TC/26 Split)
CPT 11102-11107 (biopsy), 88305 (path, with modifier TC or 26 when split)

Ophthalmology / Retina

Anti-VEGF Injections (Eylea / Lucentis / Avastin)
CPT 67028 (intravitreal injection) + J0178 (aflibercept), J2778 (ranibizumab), J9035/J7999 (bevacizumab)
OCT Imaging (Optical Coherence Tomography)
CPT 92134 (retina) / 92133 (optic nerve)

Ophthalmology

Cataract Surgery
CPT 66984 (routine) / 66982 (complex)

Pain Management

Epidural Steroid Injection (ESI)
CPT 62321/62323 (lumbar w/ imaging), 62320/62322 (cervical/thoracic), 64479-64484 (transforaminal)
Facet Joint Injection
CPT 64490-64492 (cervical/thoracic), 64493-64495 (lumbar)
Radiofrequency Ablation (Facet / Medial Branch)
CPT 64633-64634 (cervical/thoracic), 64635-64636 (lumbar/sacral)

Neurology / PM&R

EMG / Nerve Conduction Studies
CPT 95886/95885 (EMG), 95907-95913 (nerve conduction studies)

Psychiatry

TMS (Transcranial Magnetic Stimulation)
CPT 90867 (initial/mapping), 90868 (subsequent delivery), 90869 (re-mapping)
Spravato (Esketamine)
HCPCS S0013 (drug) + G2082/G2083 (administration & monitoring)

Cardiology

Cardiac Catheterization & PCI
CPT 93454-93461 (diagnostic cath), 92920-92944 (PCI / stent)
Nuclear Stress Test (Myocardial Perfusion Imaging)
CPT 78451/78452 (SPECT MPI) + 93016-93018 (stress) + J-code radiotracer
Echocardiogram (Transthoracic)
CPT 93306 (complete TTE w/ Doppler & color flow), 93303-93350 (variants)

Gastroenterology

Screening vs Diagnostic Colonoscopy
CPT 45378-45385, G0105/G0121 (screening), + modifier 33 / PT
Capsule Endoscopy
CPT 91110 (esophagus to ileum), 91111 (esophagus), 91113 (colon)

Rheumatology / Gastroenterology

Biologic / Buy-and-Bill Infusion
CPT 96365-96368/96413-96417 (infusion admin) + J-codes (J1745 infliximab, J9312 rituximab, J3357 ustekinumab)

Orthopedics / Sports Medicine

Viscosupplementation (Hyaluronic Acid Knee Injection)
CPT 20610/20611 (injection) + J-code (J7318-J7333, e.g. J7325 Synvisc)
Arthroscopy (Knee / Shoulder)
CPT 29881/29880 (knee meniscectomy), 29827 (shoulder rotator cuff repair), 29826 (subacromial decompression)

Orthopedics / Neurology

Advanced Imaging MRI (Prior-Auth Gated)
CPT 73721 (lower-extremity joint MRI), 73221 (upper-extremity joint MRI), 72148 (lumbar MRI)

Vascular Surgery / Phlebology

Vein Ablation (Varicose Vein Treatment)
CPT 36475/36476 (radiofrequency), 36478/36479 (laser), 36482/36483 (mechanochemical)

Vascular Surgery / Interventional

Peripheral Angioplasty & Stent
CPT 37220-37235 (iliac/femoral-popliteal angioplasty/stent/atherectomy)

Sleep Medicine / Pulmonology

Sleep Study (Polysomnography)
CPT 95810 (attended PSG), 95811 (PSG w/ CPAP titration), 95806/G0399 (home sleep test)

Sleep Medicine / Pulmonology / DME

CPAP / PAP Therapy
HCPCS E0601 (CPAP), E0470/E0471 (BiPAP) + CPT 94660 (initiation/management)

Neurology

Botox for Chronic Migraine
CPT 64615 (chronic migraine injection) + J0585 (onabotulinumtoxinA units)

Neurology / Immunology

IVIG Infusion
CPT 96365-96368 (infusion admin) + J-codes (J1568-J1569, J1459 immune globulin)

ENT / Otolaryngology

Balloon Sinuplasty / Sinus Surgery
CPT 31295-31298 (balloon dilation), 31256/31267/31276/31288 (functional endoscopic sinus surgery)

Urology

UroLift (Prostatic Urethral Lift)
CPT 52441 (first implant), 52442 (each additional implant)
Prostate Biopsy
CPT 55700 (needle biopsy), 55706 (transperineal/stereotactic) + 76942 (US guidance)
Cystoscopy Bundling
CPT 52000 (cystoscopy) + 52204/52224/52234-52240 (with biopsy/fulguration), 52281 (with dilation)

General Surgery

Hernia Repair
CPT 49505/49507 (inguinal), 49585/49587 (umbilical), 49650/49651 (laparoscopic)
Assistant-Surgeon Denials
Modifiers 80/82/AS on the surgical code (+ modifier 62 co-surgeon)

Plastic Surgery / General Surgery

Panniculectomy / Reconstructive Surgery
CPT 15830 (panniculectomy), 15847 (add-on abdominoplasty component)

Allergy & Immunology

Allergy Testing & Immunotherapy (95165)
CPT 95004 (percutaneous tests), 95024 (intradermal), 95165 (antigen prep, per dose), 95115/95117 (administration)

Endocrinology

CGM & Insulin Pump
CPT 95249/95250/95251 (CGM setup/interpretation), HCPCS E0784 (insulin pump), A9276-A9278 (CGM supplies)

Pulmonology / Allergy & Immunology

Asthma Biologics (Xolair / Fasenra)
J2357 (omalizumab), J0517 (benralizumab), J2182 (mepolizumab), J2786 (reslizumab) + 96372/96401 admin

OB/GYN

OB Ultrasound Frequency
CPT 76801/76802 (<14wk), 76805/76811 (fetal anatomy), 76815/76816 (limited/follow-up), 76817 (transvaginal)
NIPT & Prenatal Genetic Testing
CPT 81420 (cell-free fetal DNA aneuploidy), 81422, 0327U, 81443 (expanded carrier screening)
Global OB Split Billing
CPT 59400/59510 (global vaginal/cesarean), 59425/59426 (antepartum only), 59409/59514 (delivery only), 59430 (postpartum)

Podiatry

Routine Foot Care & Nail Debridement
CPT 11720/11721 (nail debridement), 11055-11057 (callus/corn), G0127 (nail trim) + Q7/Q8/Q9 class-findings modifiers

Nephrology

Dialysis (MCP) Billing & ESA Denials
CPT 90957-90962 (monthly capitation MCP), 90935/90937 (inpatient HD) + J0885/J0888 (ESA: epoetin/darbepoetin)

Primary Care / Internal Medicine

AWV + Same-Day Problem Visit
HCPCS G0438/G0439 (AWV), G0402 (IPPE) + CPT 99202-99215 with modifier 25
Chronic Care & Remote Monitoring (CCM / RPM)
CPT 99490/99439 (CCM), 99457/99458 (RPM treatment mgmt), 99453/99454 (RPM device/supply)

Plastic & Reconstructive Surgery

Breast Reduction (Reduction Mammaplasty)
CPT 19318 (reduction mammaplasty)

Plastic Surgery / Ophthalmology

Blepharoplasty (Functional vs Cosmetic)
CPT 15822/15823 (upper blepharoplasty), 67904/67908 (blepharoptosis repair)

Neurosurgery

Lumbar Fusion
CPT 22630/22633 (lumbar fusion / TLIF), 22612, + 22840-22853 (instrumentation)
Kyphoplasty / Vertebral Augmentation
CPT 22513/22514/22515 (percutaneous vertebral augmentation)

Infectious Disease / Primary Care

Prolonged Services & High-Level E/M Downcoding
CPT 99205/99215 + 99417 (prolonged, commercial), HCPCS G2212/G0316-G0318 (prolonged, Medicare)

Sports Medicine / Orthopedics

PRP & Regenerative Injections
CPT 0232T (PRP injection), P9020, + 20999 (unlisted regenerative)

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