Why MA Plans Denies CT Abdomen and Pelvis
Prior imaging not performed first (ultrasound, X-ray)
Diagnosis does not support advanced imaging
Duplicate study within short timeframe
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
Building Your Medical Necessity Argument
Document why less invasive imaging is insufficient
Note acute clinical findings requiring CT
Reference abnormal lab values or physical exam findings
Cite clinical suspicion for specific pathology (abscess, mass, obstruction)
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- ACR Appropriateness Criteria
- Choosing Wisely Recommendations for Abdominal Imaging
Relevant CPT Codes
Specialty: Internal Medicine / Emergency Medicine
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The P2P Playbook covers payer-specific approaches for CT Abdomen and Pelvis denied by MA Plans -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
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