03/07/2024

Healthfirst Medicare Frequency Denial for 11730

We received a frequency denial from Healthfirst Medicare on procedure code 11730 which was performed on the same toe within the 224 day time frame. We sent an appeal through the Healthfirst portal with notes to justify it was medically necessary to perform this service again however the original denial was upheld. What do you advise we do at this point?

No additional action can be taken at this point with an appeal. A dispute (reconsiderations and appeals) needs to be filed within 60 days of the date of the EOB or correspondence from Health First. Since the letter scanned was from a decision from nearly a year ago, the decision will be upheld by the managed care plan. Even if the progress notes can justify the frequency of service, it will not adjust the final determination by the plan.