By Stacie Saylor, CPC, CPB
MRS Reimbursement Advocate
December 2025
This issue first came to my attention when multiple denials of Tyenne claims were reported by different practices. The denials were consistent, raising concerns about the underlying cause and prompting a deeper investigation into the reimbursement process.
When physicians were billing for Tyenne and using two different vials to obtain the appropriate dosage, they were being denied as a duplicate procedure on the second vial.
This pattern of denial could significantly impact patient access to Tyenne, as practices struggled to receive proper reimbursement for the medication when more than one vial was required to achieve the prescribed dose. Practices expressed frustration as these denials could delay treatment initiation and increased administrative workload, necessitating additional follow-up with payers to resolve the duplicate procedure issue.
After reviewing claim samples and denials from an affected practice and clarifying follow-up questions, I concluded the problem was likely due to billing processes, not a BCBSM system issue. I confirmed this by testing claims in Clear Claim Connection via the BCBSM Availity portal.
Clear Claim Connection is an application that allows users to enter procedure codes and, optionally, diagnosis codes to assess how the claim adjudication system may process a submission. While not guaranteeing outcomes, this tool offers valuable insight by providing rationale for potential denials when such results are indicated.
From my experience, claim adjudication systems use algorithms to review specific fields in claims according to a set sequence.
For Tyenne claims with two vials billed separately, the system denied the second line as duplicate due to the procedure code before checking for unique NDC numbers.
I recommend adding modifier 59 to the claim, which indicates an extra service with the same HCPCS code. This allows the system to bypass the duplicate edit and review NDC information, resulting in both claim lines being paid correctly.
Modifier 59 – Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. (separate lesion, separate anatomical site, separate injury, separate vial)