Case Facts

Lien claimant filed a Petition for Reconsideration of Opinion and Decision After Reconsideration arguing that non-payment of services had deemed the procedures as neither reasonable nor necessary, and warranted resolution prior to the matter proceeding to independent bill review (IBR).

CostFirst Corp. filed an Answer to Petition for Reconsideration contending that non-payment of bundled procedures is not a determination of medical necessity, but that of medical coding.  CostFirst contended that the matter should have proceeded through the IBR process, of which there have been numerous determinations showing procedures that have not been recommended due to bundling or coding edit rules.

Conclusion

The Appeals Board expressed that the lien claimant was paid for some procedure codes, yet other procedure codes were denied.  The Board found that there were no issues raised of reasonableness and necessity, either implicitly or explicitly. The Board stated that pursuant to Labor Code section 4603.6(a), the dispute is subject to IBR.

The Appeals Board denied lien claimant’s Petition for Reconsideration.