Retina Clinics: That Drug or Procedure May Not Be Medically Necessary

Medical Billing

Medical Documentation

Nov 12, 2024

Apr 3, 2025

Written By Elizabeth Cifers

Written By

After the exam is done and any diagnostic tests or injections have been completed, a moment of truth arrives: “Was it all medically necessary?” The procedures may have been performed in the patient's best interest, but the medical necessity of each must still be demonstrated to the insurance payer for proper reimbursement. Many separate pieces must come together in perfect harmony for a clear picture of medical necessity to be apparent, and each represents an opportunity for error. However, retina practices can avoid medical necessity pitfalls through proper process, documentation, coding, and billing.

Several pitfalls that commonly result in denials due to a lack of medical necessity include:

Not properly documenting the medical reason for switching drugs. The documentation should clearly explain how the current drug fails to achieve the desired medical outcome, what the physician wants to see, and why the physician expects the new drug to succeed in meeting the outcome if the practice is going to be reimbursed.

Performing a diagnostic test without proper medical justification. The patient must exhibit signs and symptoms observed in an exam indicating a qualifying reimbursement diagnosis.

Failing to provide an interpretation and report (I&R). Interpretation and report should support the diagnosis and, therefore, the medical necessity of the test, which is required for payer reimbursement of most diagnostic tests used in retina practices.

Billing an unnecessary diagnostic test. If multiple tests are performed, only those that support the diagnosis and, therefore, the medical necessity of the test should be billed. Improper unbundling of diagnostic tests with modifiers can be problematic even if the diagnosis is supported.

Issues with diagnosis(es). Perhaps the incorrect diagnosis code was selected, or the diagnosis isn’t on the payer’s list of payable diagnoses despite being an FDA-approved diagnosis. Remember, the diagnosis is the foundation of support for drugs and procedures, so issues in this area can affect multiple claim lines.

Medical necessity is a multifaceted concept that hinges on reason and diagnoses. Proving to an insurance payer that a procedure is medically necessary requires attentiveness to published requirements, thorough and accurate documentation, and correct coding. Retina practices survive by reimbursement, so consistent support for the medical necessity of drugs and procedures should be made a top priority if it isn’t already.

If “lack of medical necessity” is a recurrent theme for denials at your retina practice, consider recruiting the help of an expert who can identify potential causes and recommend process changes that can help eliminate source issues in the future. Retina practice consultant Elizabeth Cifers, MBA, MSW, CHC, CPC, has a keen eye for patterns of error after decades in the industry, including 13 years in retina practice administration and a position at a leading U.S. eye care consulting firm. She is an expert in mitigating medical necessity denials in retina and can help you ensure this area for proper reimbursement over the life of your practice. Schedule a complimentary consultation with Elizabeth today: https://calendly.com/elizabethcconsulting/free-consultation-call.

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Retina Clinics: That Drug or Procedure May Not Be Medically Necessary

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