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Horizon 98943 & 97014 Denials

We have recently heard from many members that CPT codes 98943 and 97014 are being denied on various (but not all) Horizon plans. We have seen these denials with two different reason codes. 

 The more common is reason code U702: “This service is not paid. This denial occurred because the procedure code has a status indicator of N, I, P, M, R or C. Refer to the Medicare Physician Fee Schedule to determine CMS Guidelines for reimbursement.”

 We have also seen reason code CO-272: “Coverage/program guidelines were not met. Start: 11/01/2015.” 

We have spoken to Horizon management to alert them of these denials. They are researching the issue.  We have not yet seen or heard any indication that this is a new intentional policy to cease payment of 98943.  

 Medicare and some commercial payers reimburse 97014 (unattended electrical stimulation) under code G0283 instead. This may explain the 97014 denials. We will alert membership as soon as we have more information or a resolution.