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UPIC's Claim Denials for Sedation Are Ripe for Appeal, Lawyer Says

Recent claim denials by a unified program integrity contractor (UPIC) are a reminder to providers to consider submitting more documentation than auditors request and to question the basis of denials rooted in a local coverage determination (LCD), an attorney said.

The UPIC denied about half the claims submitted by one pain management clinic for facet joint injections (delivered to the spine) and conscious sedation administered before the procedure, said Minneapolis attorney David Glaser, who represents the clinic. The UPIC said the services weren’t reasonable and necessary and documentation was insufficient, said Glaser, with Fredrikson & Byron.

The denial letter cited LCD 35937, which states that “local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.”[1] The UPIC then went on to say that with respect to the medical records for the pain management clinic, “the general statement was the same for all beneficiaries having conscious sedation; ‘The patient was anxious prior to the procedure and requested conscious sedation.’ The statement is vague, not clearly documented, not unequivocal and is too generic to justify conscious sedation for these types of procedures. For this reason, the services are denied.”

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