JAN 18, 2023
Drug and Injection Recoupment
Question: A patient needed Eylea for wet AMD, and we were not able to get prior authorization. The payer did not cover the drug and is recouping the payment for 67028. Is a payer allowed to recoup both the drug and the procedure when prior authorization is only required for the drug? What about when a sample drug is used?
Answer: Payers can and will deny the injection if the drug is denied as not reasonable and necessary (no prior authorization is obtained to establish medical necessity). This is consistent with Medicare policy as stated in National Government Services local coverage article (LCA) A52451:
“If the drug is denied as not reasonable and necessary, the associated injection code will also be denied,” according to the Centers for Medicare & Medicaid Services article Billing and Coding: Ranibizumab, Aflibercept and Brolucizumab-dbll and Faricimab-svoa (A52451).
If a sample is denied as not medically necessary, the 67028 can be recouped. Review how to submit a claim with a sample drug.