Happy Friday to everybody! We have started seeing a trend with Aetna in general with denials for investigational/experiemental reasons on multiple CPTS. Since we provide the professional interpretations only, we end up on the back side of items and it can take a little bit to figure out what is going on.
The first issue has to do with their (Aetna's) PET scan policy – it does NOT mirror CMS' NCD by any means, and we are currently battling them over studies that HAD been pre-authorized (they now routinely tell the referring offices that these do NOT require pre-authorization, but of course never mention that they have their own PET scan policy).
Today however is the icing on the cake: We have them telling us that a Screening Mammogram with ICD-10 code Z12.31 that denied as "experimental" is in fact a correct denial!! Still scratching my head on this one – but they referred us back to their policy (yes, they have their own policy for Mammograms too!) where it is very clear that this is an incorrect denial (this patient meets age criteria, has been far longer than a year from her last one, and Z12.31 is listed on the covered indications if criteria is met).
After walking through the policy with my Patient Account Rep, she called Aetna back to go back over this: This time the Aetna Rep began to tell us that we would have to print a copy (of their policy), highlight the exact pages showing the coverage, and include a full Aetna Appeal with it -- ??? Needless to say I got involved on the call with her at that point and pointed out that was NOT going to happen. The staff we are speaking to are very hard to understand, and obviously have standard instructions to continue to deny, and to instruct the providers office that we must provide print outs of their policies, do full appeals, etc., even when they are incorrect in their denial. She is supposed to send this back for reprocessing, but I highly doubt this will happen, or if it does, it will deny out as a duplicate OR with the same incorrect experimental denial reason.
It is a concerning trend that I have begun to see from Aetna in denials for experimental &/or investigational reasons on items such as the screening mammograms, but even more so, the outsourced Provider Service department that appears to have instructions not to send back for reprocessing or to investigate from their end at all.
Of course we no longer have any individual Provider Reps to speak with, and while the Screening Mammograms certainly fall into the realm of Legislative coverage issues that we can follow-up with if they continue, we find ourselves building the amount of time we are spending on Aetna issues. We will be taking all of these items into consideration as we look at our Aetna policy and what our future plans will be, however, I would appreciate any feedback from any of you if you are experiencing the same or similar issues, and if you've found anybody at Aetna to contact that has assisted with these.
Thank you in advance for your time,
Michelle
Michelle R. Juette, CPC, RCC
Business Services Manager
Yakima Valley Radiology
(509) 895-0402 (direct, voice/mail)
(509) 248-0733 (secure fax)
mailto:mjuette@yakrad.com