APPEAL LETTER FOR DENIED REPAIRS
Many excision procedures for benign and malignant skin lesions result in defects that require a layered repair
to meet the standard of care. The AAD STATEMENT ON LAYERED CLOSURE in Derm Coding Consult,
March 1997, details the clinical indications for layered closure.
Most insurance carriers recognize the medical necessity and separate nature of layered repairs. AMA/CPT is
very specific in its descriptors that excisions only include simple (non-layered) closure, and the RVU for
excisions reflects that fact. Layered repairs also have accepted RVUs, and when both procedures are needed
on the same lesion, the reimbursement for the lesser procedure may be reduced by 50% because of the
multiple surgery rule.
Unfortunately, some software edits inappropriately bundle excisions and repair procedures, misrepresenting
one service as incidental to the other in order to limit payment. If a dermatologist experiences such
inappropriate bundling, an appeal to the Medical Director is advised. A sample letter follows.
_____________________________, MD, Medical Director
(name of ins. co.)
Policy Number: ______________________
Date of Service:______________________
Re: Inappropriate bundling of excision and repair
We have received a payment explanation from (name of ins. co.) on the above claim. This explanation
reflects a deviation from the current industry standard reimbursement for excisions and repairs, in that
separate payment was not made for the excision (code [fill in]) and the repair (code [fill in]).
AMA/CPT states that excision includes simple (non-layered) closure only. Necessary intermediate or complex
repairs are not included in the excision codes and are coded in addition to the excision. The RVU for an
excision only covers the excision including a simple repair and does not reflect the additional physician work
for an intermediate or complex repair.
The bundling of excisions and repairs by (name of ins. co.) is inappropriate according to AMA/CPT. Medicare
policy allows reimbursement for intermediate and complex repairs. We do acknowledge that the multiple
surgery rule would be applied, thus reducing the lesser procedure by 50%.
Please review (name of ins. co.) policy on the erroneous bundling of excision and repair, and make the
appropriate additional payment. We also request that (name of ins. co.) change their policy on excisions and
repairs so that such claims can be paid correctly when submitted without the need for appeal letters later.