A family from Kansas with health insurance coverage through Cigna had their teenage son admitted to Elevations RTC (Elevations), a residential treatment center (RTC) in Syracuse, Utah, from June 1, 2022, to March 1, 2023. Upon admission to Elevations, Cigna authorized the child’s residential care from June 1, 2022, to July 12, 2022. As of July 13, 2022, Cigna denied continued residential treatment as being not medically necessary.
This family reached out to the team at FixMyClaim in August 2022 for assistance pursuing reimbursement for their child’s ongoing treatment at Elevations, which would require both billing claims and completing appeals. The FixMyClaim billing team submitted claims to Cigna throughout the patient’s stay, which by discharge totaled $197,200.00.
Concurrently, we assisted the family in requesting and obtaining medical records from previous providers, which served to document their son’s functional deterioration and failure to improve despite extensive treatment in less intensive and less sustained levels of care. In conjunction with Elevations’ detailed medical records, these supporting clinical documents formed the foundation of the appeal record. Armed with this information, our expert appeals team crafted an extensive appeal letter totaling 53 pages, which thoroughly refuted Cigna’s medical necessity denial. The complete appeal package submitted to Cigna on January 17, 2023, totaled 2,558 pages.
Unfortunately, on February 22, 2023, Cigna’s reviewer decided to uphold the initial denial on the basis that continued treatment could instead be provided at a less restrictive level of care. Our expert appeals team then prepared an external or independent review organization (IRO) request totaling 3,088 pages, which was submitted to Cigna on March 22, 2023.
When the team at FixMyClaim followed up on the status of the appeal on April 24, 2023, Cigna claimed to have no record of the appeal (despite having a confirmed delivery and return receipt), and requested that the appeal be resubmitted in its entirety. Upon assessing the situation, the team at FixMyClaim decided to proceed with resubmitting the entire external appeal package, which was shipped out on April 26, 2023, and the team confirmed that Cigna received the full resubmission on May 2, 2023.
The team at FixMyClaim continued to diligently follow-up on the status of the external appeal on May 30, 2023, June 7, 2023, June 12, 2023, and June 19, 2023, until this family’s case was assigned to MES Peer Review Services (MES) on June 21, 2023. On July 26, 2023, MES concluded that services from July 13, 2022, and going forward was medically necessary. However, because Cigna failed to provide the reviewer with the full medical records beyond January 15, 2023, the MES reviewer could only approve services from July 13, 2022, to January 15, 2023.
For the remaining services from January 16, 2023, to March 1, 2023, it took several months of consistent follow-up before these services were finally reviewed. On November 8, 2023, Cigna finally launched a second external appeal to MES for evaluation. On December 12, 2023, MES’s reviewer concluded that the final portion of the patient’s stay at Elevations from January 16, 2023, to March 1, 2023, was likewise medically necessary.
Overturn: https://fixmyclaim.com/wp-content/uploads/2024/02/fmc5-3365-overturn-letter.pdf