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Anthem Denials
February 27, 2019

Anthem BCBS has been keeping chiropractic offices across the state especially busy in early 2019. There have been a number of issues which have been resulting in claim denials.

1. Denials of procedure code G0283 being denied as investigational/experimental. G0283 is Electrical Stimulation, Unattended, one or more areas and is a covered code for Anthem BCBS.

  • Resolution: Denials were incorrect and an Appeal must be submitted in order to have the claim reprocess for payment.

2. Change in documentation guidelines to follow Medicare guidelines (i.e. documentation show pain, Outcome Assessments and functional improvement for all patients).

  • Resolution: We are still confirming if this applies in Wisconsin, since Anthem BCBS has different requirements by State. However, consider performing an internal audit on your Anthem BCBS documentation to ensure it is up to Medicare standards-this can only help you to show medical necessity.

3. Claim denials from Anthem BCBS due to the combination of diagnosis codes used being considered mutually exclusive. Going on since mid December or January.

Some of the code combinations that have been resulting in claim denials are:

S33.140D and M53.2X7
S33.5XXA and M51.26 and also M51.36

  • Resolution: We are currently waiting to hear back with information from Anthem if they had any coding edit changes. The main diagnosis codes resulting in denials currently are the S-codes. According to ChiroCode, “the S33.1- codes are controversial to many. Some feel that CMT is contraindicated for this diagnosis. Click here to read a ChiroCode article about the problem. Using the “S” diagnosis codes with other codes could appear to be contradictory since the "S" codes are for injuries. For example, if used with M51.37 Other intervertebral disc degeneration, lumbosacral region, the insurance carrier may question if this was this an injury or a degenerative condition? If the patient really did satisfy BOTH, you could appeal with the documentation of both conditions. However, it might be easier to simply submit a corrected claim with an M99- as the primary diagnosis.

4. Vague claim denials with explanation codes 066 and/or 45:

  • Resolution: Checking with Anthem, so far submitting medical records seems to be the resolution for this issue, we are continuing to investigate this.

CBD Oil Update

February 7, 2019

With the recent passage of the 2018 Federal Farm Bill which contained a provision on agricultural Hemp, the WCA Help Desk has been receiving questions on whether this will allow Wisconsin Chiropractors to sell hemp oil products, including hemp-derived CBD oil. The Farm Bill was signed by the President at the end of December, and legalizes hemp at the Federal level, provided that it contains no more than 0.3% tetrahydrocannabinol (THC).

However, the Farm Bill does not alter the Food, Drug and Cosmetic Act nor does it affect the FDA’s authority.  As a result, changing the status of Hemp from a controlled substance does not affect the FDA’s conclusion that CBD products are classified as a drug, and not a nutritional product.

Following the passage of the 2018 Federal Farm Bill, the FDA issued a statement reminding people that, “it’s unlawful under the FD&C Act to introduce food containing added CBD or THC into interstate commerce, or to market CBD or THC products as, or in, dietary supplements,regardless of whether the substances are hemp-derived. This is because both CBD and THC are active ingredients in FDA-approved drugs and were the subject of substantial clinical investigations before they were marketed as foods or dietary supplements. Under the FD&C Act, it’s illegal to introduce drug ingredients like these into the food supply, or to market them as dietary supplements.”

The statement also clarified that, “...some foods are derived from parts of the hemp plant that may not contain CBD or THC, meaning that their addition to foods might not raise the same issues as the addition of drug ingredients like CBD and THC. We are able to advance the lawful marketing of three such ingredients today. We are announcing that the agency has completed our evaluation of three Generally Recognized as Safe (GRAS) notices related to hulled hemp seeds, hemp seed protein and hemp seed oil and that the agency had no questions regarding the company’s conclusion that the use of such products as described in the notices is safe. Therefore, these products can be legally marketed in human foods for these uses without food additive approval, provided they comply with all other requirements and do not make disease treatment claims.”

[Emphasis has been added, you can read the full statement here: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm]

Until the law (or legal authorities) label CDB as a dietary supplement or food, and not a drug, Wisconsin-based DCs take a risk with practicing outside their scope by selling or prescribing CBD products, including hemp oil, hemp cream and hemp complexes that contain CBD.  Currently, Wisconsin chiropractors are prohibited from prescribing, dispensing, delivery or administration of drugs as defined in Wis Stat. s. 450.01(10), which defines drugs as including any substance intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease or other conditions in persons or other animals.  The chiropractic code excludes from drugs vitamins, herbs or nutritional supplements consistent with the chiropractic nutritional counseling certification law, also see Wis. Admin. Code s. 4.05(d).The FDA has deemed CBD oil a drug, not a food or nutritional supplement. The FDA has issued warning letters to many manufacturers of CBD products for misrepresentations of their products, and will likely continue to do so, seehttps://www.fda.gov/newsevents/publichealthfocus/ucm484109.htm
 

At this point in time, the WCA does not recommend that you sell CBD oil products, due to the potential risk it could pose to your license. If you are interested in learning more about hemp products which do not contain CBD or THC, we encourage you to consult with potential vendors and distributors to verify that their products do not contain these substances.