By Nargiza Nurlibayeva, Billing Department, WCH
In September 2023, our office began billing a series of claims for amniotic membrane services under CPT 65778. The documentation met every criterion in the payer’s own clinical policy. The members’ benefit verification confirmed coverage for the procedure. Based on the documentation submitted, applicable coding guidance, and the payer’s stated coverage criteria, these claims appeared to meet the requirements for payment within the normal reimbursement cycle.
They were not paid until July 2026. Getting there took nearly three years of appeals, escalations, and correspondence with a payer whose internal structure made it difficult to identify a single accountable person responsible for resolving the dispute. This article walks through what that process actually looked like, why the appeals system itself contributed to the delay, and what finally moved the claims to payment.
The Pattern
Anyone who has spent time in provider relations or claims appeals will recognize the sequence. It rarely varies.
First comes the policy citation. The payer confirms that the procedure code is listed in the relevant clinical policy, then adds that inclusion in a policy does not guarantee payment. This is accurate as far as it goes, and it answers nothing. It does not say whether the claim was denied for lack of medical necessity, a benefit exclusion, a contracting issue, or a coding conflict. It simply restates that coverage is not automatic — something no provider disputed in the first place.
Next comes the handoff. The claims department says the issue belongs to utilization management. Utilization management says it’s a claims matter, not a medical review question. The clinical policy analyst says scope of practice is a state licensing issue, not something the payer determines. Each department may have been addressing a legitimate part of the issue, but the result was that no single team took ownership of resolving the underlying dispute.
Then comes the appeal redirect, which is the part that does the most damage. Once the file has been through this handoff cycle a few times, the standard response becomes “file a formal appeal” — regardless of whether an appeal has already been filed, already been denied, and the filing window has already closed. At that point, telling a provider to appeal is not guidance. It’s a way of closing the conversation without resolving it.
Finally, when an appeal is actually reviewed, the determination upholds the original denial in language that could apply to almost any claim. It does not address the specific documentation submitted or the specific coding argument made. The provider is left with a denial and no clearer understanding of what would change the outcome.
The following timeline shows how a claim that met documented coverage criteria moved through nearly three years of review, escalation, and resolution.
| Case Timeline: From Initial Claim Submission to Payment |
| September 2023 Claims submitted for amniotic membrane services under CPT 65778. |
| 2023–2024 Denials received; clarification requests and departmental transfers followed. |
| 2025–2026 Escalation through documented correspondence and requests for substantive review. |
| July 2026 Claims reviewed and paid after nearly three years of follow-up. |
The Appeal Window Is Part of the Problem
One detail in this case deserves more scrutiny than it usually gets. Appeal determinations were mailed rather than sent electronically, while the response windows were short — 30 days for an initial appeal, 15 days following reconsideration. The clock starts from the date of the decision, not the date the provider actually receives it in the mail. By the time a determination arrives, is logged, and is routed to the person who can act on it, a meaningful portion of the response window is already gone.
This is not incidental. A short window combined with mail delivery and boilerplate denial language produces a predictable outcome: providers miss deadlines, submit rushed responses, or simply stop pursuing claims they know are valid. None of that requires bad faith on any individual’s part. It’s just how the process is built.
What Actually Changed the Outcome
Appeals were exhausted. Filing another one was not an option, and continuing to ask the payer to “reconsider” only fed the same loop. What changed the trajectory was a shift in what we were asking for.
Instead of requesting that the appeal be reopened, we asked for something the process doesn’t formally provide for: a review by someone with the knowledge and authority to look at the actual clinical and coding issue, separate from the appeals mechanism. We said this explicitly, in writing, more than once — this was not a request to restart an appeal, but a request for a named, accountable point of contact.
It took roughly a year of repeated written summaries — laying out NCCI edits, MUEs, LCDs, and NCDs relevant to the code, and documenting the contradictions in the payer’s own prior responses — before someone inside the organization agreed to look at the substance rather than route the file to the next department. Once that happened, resolution followed in weeks, not years.
What This Means for Billing and Compliance Work
A few things from this case are worth carrying into other disputes.
Get every redirect in writing. When a representative says an issue is outside their department, ask them to name the correct one, and keep the response. It builds a record that the provider made repeated, documented, good-faith attempts to resolve the issue — which matters if the dispute ever needs to go to a state insurance regulator.
Separate the appeal request from the review request. Once an appeal window has closed, stop asking for an appeal. Ask, explicitly, for a substantive review outside the appeals process, and state clearly that this is not a request to reopen one. Conflating the two gives the payer an easy way to redirect you back into the process that already failed.
Use the payer’s own clinical policy against the denial. If a policy lists a procedure code along with specific medical-necessity criteria, and the documentation meets those criteria, the payer should be able to identify the specific provision that supports a denial despite the claim meeting the stated policy criteria. “The policy doesn’t guarantee payment” is not that provision.
Track dates precisely — decision date versus receipt date. Where a pattern emerges of short appeal windows combined with mailed determinations, document it. It’s a legitimate basis for a complaint to a state insurance department if it recurs.
Escalate past provider relations. Representatives at that level are often not authorized to resolve coding or coverage disputes; their job is largely to relay answers from other departments. When someone says they’ve “provided all available guidance,” treat it as the point to escalate, not the end of the conversation.
Medical necessity, when properly documented and aligned with a payer’s own clinical policy, should provide a clear basis for payment. In practice, however, providers often find themselves defending not the clinical decision itself, but their ability to obtain a meaningful review of that decision. In complex payer disputes, resolution often begins when the question changes from “Why was this denied?” to “Who has the authority to explain and resolve this decision?”
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