How to Avoid Insurance Denials for Prescribing a Biologic Without MTX in Concert

The Insurance Subcommittee (ISC) of the ACR’s Committee on Rheumatologic Care (CORC) has recently received a number of reports from members regarding denials for biologics for patients not on methotrexate. To help avoid an often-lengthy appeals process, the ACR/ARHP recommends that members document a patient’s history of methotrexate intolerance or contraindication at every visit.

What to Document
At minimum, documentation of each patient encounter should include:

• The reason for the visit;
• The relevant history;
• Physical exam findings;
• Prior diagnostic test results;
• Assessment, clinical impression or diagnosis; and
• Plan of care.

The patient’s progress and response to and changes in treatment(s) and revisions should also be documented.

Some of these areas may be adjusted to account for the varying circumstances encountered by the provider at each visit, but it is important to ensure the necessary documentation is in the patient’s medical record to support the level of care.

Documenting the Biologic/Methotrexate Combo
For biologics normally prescribed in combination with methotrexate, consistently documenting the reason for the exception, ideally at each encounter, is key to ensuring timely payment by the insurance company. Documenting this reason is important even for patients on long-term therapy. The payer will review the chart notes submitted with each claim; however, there is no guarantee they will have access to previous claims or health records. Therefore, documenting the intolerance or contraindication at every visit ensures the payer has the necessary information to approve the claim without delay.

Need Help?
If you have a patient with an insurance policy that prohibits biologic monotherapy, regardless of the patient’s ability to tolerate methotrexate, let the ISC know. Also, ACR coders are available to assist with any coding guidelines or chart reviews for required clinical documentation for individual claims. Send an email to practice@rheumatology.org for further details.