Insurance coverage/billing codes

I have BCBS. My plan allows 25 PT visits a year SOFT max, so they should approve more if medically necessary.

I have been dealing with Frozen Shoulder for almost 2 years. Unfortunately the first doctor misdiagnosed me with a partial rotator cuff tear. I did PT, got a little better but still a lot of pain.

Pain got worse, shoulder froze hard. New doc diagnoses with Frozen Shoulder. First line of conservative treatment is PT. I did 25 visits. Although my shoulder improved it didn’t improve enough and was still stuck. Doc recommended surgery. I had surgery on July 13. Insurance covered surgery, etc.

Now going to PT for post surgical Pt and shoulder is improving leaps and bounds. Dr office sent insurance a request for additional PT including a script for PT and post surgical notes. Insurance is denying coverage for all post surgical PT even though it is medically necessary.

I’ve gotten 2 different denial letters from BCBS about this. First one said everything denied. 2nd one said use restorative PT codes Vs. maintenance PT codes. I talked to PT billing and they have no idea what the difference between restorative code vs Maint code (never heard of it) and when I called BCBS to ask they said they can’t provide me with that information.

I think my next steps is an appeal process or figuring out what codes BCBS is talking about as restorative. Only thing I found on internet is adding a -55 to code that will code it post surgery care. Is this all they are looking for?

Any help would be appreciated. I’ve already spent hours on the phone with BCBS with no answers. And since surgery I have already done 13 PT visits. If insurance doesn’t cover I will have to pay out of pocket and probably discontinue PT which could be detrimental in the long run. A big F-U to BCBS

submitted by /u/throwawaythetrash54
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