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A claim was denied by Blue Cross Blue Shield (BCBS) for no authorization of a follow up test performed three months after an Essure procedure (a form of birth control). The surgeon did not obtain an authorization for the follow up procedure as their payment for the underlying procedure includes payment for this test.

After researching the procedure, Convergent submitted an appeal to BCBS arguing that, since the follow up test is an essential part of the procedure, this follow up test should be deemed included in the authorization for the procedure itself.

Convergent used the following language in its appeal to the BCBS:

The Essure procedure involves placement of soft, flexible Essure inserts into the fallopian tubes. Over a period of three months, the body interacts with the inserts to create a natural barrier blocking the fallopian tube. The Essure confirmation test is an integral part of the procedure and must be performed 3 months after the placement of the inserts to assure that the barriers are in place. Here, Ms. [NAME] underwent the Essure confirmation test which confirmed that the barriers were in place and that she could now rely on the Essure as her only form of birth control. As this confirmation test is an integral part of the Essure procedure, we maintain that in authorizing the Essure procedure, this portion of it was also authorized. Therefore, please process the claim with the authorization that was issued for the patient’s Essure procedure performed in [DATE]. If BCBS does not deem the authorization included in the authorization that was initially granted for the Essure procedure, then we request that the Essure procedure authorization either be extended to include this confirmation test or a new authorization be issued for this date of service. Clearly, this confirmation test was medically necessary to ensure that the barriers were in place and that the procedure was a complete success.

BCBS accepted the appeal and approved payment in the amount of $934.21.