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Aetna requesting medical documentation.
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Re: Aetna requesting medical documentation.
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sporty981
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Oct 24 10 6:53 AM
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Looking at the policy bulletin for Aetna
http://www.aetna.com/cpb/medical/data/1_99/0016.html
under the policy history if you click on the last review 5/14/10 it states
"This CPB is revised to state that facet injections are considered medically necessary for diagnosis of facet-mediated back pain. This CPB is revised to state that facet injections are considered experimental and investigational as a treatment for back pain"
I believe that's why you're getting denied now. The review did not change the policy. Under clinical policy they are reserving the right to decide to pay on experimental based on a case by case approach.
Aetna considers any of the following injections or procedures medically necessary for the treatment of back pain; provided, however, that only one invasive modality or procedure will be considered medically necessary at a time.
Facet joint injections are considered medically necessary in the diagnosis of facet pain in persons with chronic back or neck pain (pain lasting more than 3 months despite appropriate conservative treatment).
Facet joint injections are considered experimental and investigational as therapy for back and neck pain and for all other indications.
A set of facet joint injections means up to 6 injections per sitting, and this can be repeated once to establish the diagnosis. It is not considered medically necessary to repeat facet joint injections more frequently than once every 7 days. Additional sets of facet injections are considered experimental and investigational because they have no proven value.
I don't know if that helps you but this is what I got out of their policy now I don't know if it's one a year or what their limits are that's where I would call and ask also ask for a review.
Karen Habel, CDA, CMBSI, CDBSI
Nothing I say shall be construed as legal advice; always check with your own financial or legal advisors for your specific situation.
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Association News
Medical Billing & Coding Education from the MAB
Continuing Education
Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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