How To Fix Denial Code 55 | Common Reasons, Next Steps & How To Avoid It

Denial Code 55 means that the procedure, treatment, or drug being billed is considered experimental or investigational by the payer. This denial code indicates that the insurance company will not provide payment for the service because it is not considered a proven or established treatment option. In this article, we will explore the description of Denial Code 55, common reasons for its occurrence, next steps to address the denial, how to avoid it in the future, and provide examples of cases where Denial Code 55 may be encountered.

2. Description

Denial Code 55 is a Claim Adjustment Reason Code (CARC) that signifies that the procedure, treatment, or drug being billed is deemed experimental or investigational by the payer. This means that the insurance company considers the service to be unproven or not yet established as an effective treatment option. As a result, the claim is denied, and the insurance company will not provide reimbursement for the service.

2. Common Reasons

The most common reasons for Denial Code 55 are:

1. Lack of Medical Necessity Evidence: Insurance companies require strong evidence of medical necessity to cover a procedure, treatment, or drug. If the provider fails to provide sufficient documentation or clinical evidence supporting the effectiveness and necessity of the service, the claim may be denied under Denial Code 55.
2. Limited Coverage Policies: Some insurance plans have specific policies that exclude coverage for experimental or investigational procedures, treatments, or drugs. If the service falls under this category, the claim will be denied under Denial Code 55.
3. Non-Recognition of New Treatments: Insurance companies may take time to recognize and approve new treatments or procedures. If the service being billed is relatively new and not yet widely accepted or established, it may be considered experimental or investigational, resulting in a denial under Denial Code 55.
4. Insufficient Research or Clinical Trials: If there is a lack of sufficient research or clinical trials supporting the effectiveness and safety of a procedure, treatment, or drug, it may be deemed experimental or investigational by the payer. In such cases, the claim will be denied under Denial Code 55.

3. Next Steps

If you receive a denial under Denial Code 55, here are the next steps to address it:

1. Review Documentation: Carefully review the documentation submitted with the claim to ensure that it includes comprehensive evidence of medical necessity. If any supporting documentation is missing or incomplete, gather the necessary information and resubmit the claim with the additional documentation.
2. Consult with the Payer: Contact the insurance company to discuss the denial and seek clarification on their specific criteria for considering a service as experimental or investigational. Understand their requirements and determine if there is any additional information or documentation that can be provided to support the claim.
3. Appeal the Denial: If you believe that the service should not be considered experimental or investigational, and you have sufficient evidence to support its effectiveness and medical necessity, file an appeal with the insurance company. Follow their appeal process and provide all relevant documentation to strengthen your case.
4. Explore Alternative Coverage Options: In some cases, alternative coverage options may be available. Research other insurance plans or programs that may cover the procedure, treatment, or drug in question. This could involve exploring clinical trials, research studies, or compassionate use programs.

4. How To Avoid It

To avoid Denial Code 55 in the future, consider the following strategies:

1. Verify Coverage Policies: Before providing a procedure, treatment, or drug, verify the patient’s insurance coverage and review the policy for any exclusions or limitations related to experimental or investigational services. If the service is not covered, inform the patient in advance and explore alternative options.
2. Document Medical Necessity: Ensure that all documentation clearly demonstrates the medical necessity of the service being provided. Include comprehensive clinical evidence, research studies, and any other supporting information that establishes the effectiveness and appropriateness of the procedure, treatment, or drug.
3. Stay Informed: Keep up-to-date with the latest research and clinical trials in your field. Stay informed about emerging treatments and procedures to determine if they are gaining recognition and acceptance within the medical community and insurance industry.
4. Communicate with Payers: Establish open lines of communication with insurance companies to understand their coverage policies and criteria for considering a service as experimental or investigational. Seek pre-authorization or pre-determination when necessary to ensure clarity on coverage.

5. Example Cases

Here are two examples of cases where Denial Code 55 may be encountered:

• Example 1: A provider submits a claim for a cutting-edge cancer treatment that is still in the experimental phase. The insurance company denies the claim under Denial Code 55, as the treatment has not yet been proven effective through extensive clinical trials.
• Example 2: A patient undergoes a procedure that is considered experimental for their specific condition. The provider submits a claim, but the insurance company denies it under Denial Code 55, citing the lack of established evidence supporting the procedure’s effectiveness.

Source: Claim Adjustment Reason Codes