Demanding Peer Review of Assistant Surgeon Denials

“The decision to request that a physician assist at surgery remains the responsibility of the primary surgeon and, when necessary, should be a payable service.”

This familiar statement is part of the ACS Physicians as Assistants at Surgery 2007 Study which is widely used to determine insurance coverage for assistant surgeons and other surgical assisting fees.

Appeals are often necessity to address the medical necessity of surgical assistants. To effectively appeals such denials is important to address the following in each appeal:

1. Describe the procedure. Review the operative report for any comments regarding surgical challenges included use of surgical instruments and/or hardware, excessive scarring, complicating secondary diagnoses or interoperative monitoring requirements which necessitate additional personnel.
2. Describe assistant surgeon’s activities. The operative report may give a very basic description of the assistant surgeon’s activities. Your appeal should provide as detailed a description as possible including a step-by-step description of how the assistant was involved in the patient’s care.
3. Demand peer review of the denial. It is important to seek peer review of any denial which directly affects the quality of care provided by your organization. Use wording such as the following or customize the wording to cite potentially applicable legal protections related to the denial:

It is our position that your organization’s clinical review criteria may allow benefits for an assistant surgeon as long as the medical necessity criteria have been met. Attached are the medical records which reference the need for the assistant surgeon. Specifically, the assistant surgeon’s activities during the procedure are consistent with the national standards established to assure the patient’s safety and improve the likelihood of a successful outcome. As you know, many state and federal claim processing regulations require peer review of a health benefit denial. Therefore, we request that a board certified (insert specialty, ie orthopedic, pediatric) surgeon review the denial of benefits for the assistant surgeon ordered by the lead surgeon. If the medical records do not sufficiently demonstrate the medical necessity of the assistant surgeon, please have the surgeon responsible for the specialty care peer review to contact Dr. (insert lead surgeon’s name) immediately. This will allow Dr. (lead surgeon) to more completely describe the necessity of the assistant surgeon during this procedure.