AETNA denying coverage of ultrasounds

F2M n Spouse

OB office called this morning stating Aetna won't cover the 20 week ultrasound and we will have to fork out several hundred to have one done. Needless to say we're LIVID!!!

For anyone who has Aetna do you know what "diagnosis" is needed to be billed to have the ultrasound covered? A rep told us that the only way the ultrasound will be covered is if it's billed under a covered medical diagnosis.

I don't know how the OB office doesn't know the ins and outs of our insurance when they only accept a few but they know Aetna gives them a hard time about covering ultrasounds.

2moms_somewhere

Aetna covered mine for this pregnancy and my past, as well as the harmony test and NT scan. I believe the diagnosis is just pregnant. I would just call them and ask. It is a pain to get through, but once you are through they are generally helpful. I know each plan is very different, so maybe your plan has completely different coverage. Good luck.

JandRVA

They should allow one anatomy ultrasound per pregnancy. I wonder if your OB's office used the wrong CPT code. If they used 76811, then you would need a high-risk diagnosis since it's an indication-driven code typically used by a MFM (it's a detailed anatomy scan). Without a valid medical reason, the insurance company would likely deny coverage. The basic anatomy scan CPT code that should be used is 76805.

And in case it helps, the diagnosis code for a routine singleton pregnancy is Z33.1 in ICD-10 (I can't remember what it was in ICD-9 but I can find that out for you if you need it - this is part of what I do professionally).

I would call Aetna to find out why it was being denied. It may be something other than a wrong CPT code like a provider issue (the radiologist may be out of network) or that your plan requires pre-authorization.

F2M n Spouse

She said the reasons it's being denied is because they submitted it under two codes 76811 and 76817 meaning it's a normal pregnancy and they don't cover more than 1 ultrasound if everything is normal.

I am overweight and have high blood pressure and she wouldn't tell me exactly what the diagnoses needs to be to have coverage but that to go to Aetna.com and it will tell you. Well we did and the only thing I could find that would maybe get the ultrasound covered is being overweight and having high blood pressure. But it's a crab shoot since I don't know if definitively it will be covered or not since they're not going to run it until we show up for the ultrasound.

I know my OB is in network because I called Aetna to ask for OBs covered in our area and they gave me a list.

K&H

I've heard that most insurance companies will cover services if you call and are persistent enough in your appeal. I would call the insurance company yourself and push until you get a clear answer.

JandRVA

They used 76817 for a 20 week scan or was it used for an earlier ultrasound? CPT 76817 is used for transvaginal ultrasound (typically for dating purposes in first trimester or cervical length monitoring in later pregnancy).

I also have Aetna and they have covered all of my ultrasounds. I would call to hound them for an answer regarding the coverage and exactly what CPT codes would be approved (likely it will be either 76805 or 76811 - though they already denied that one). Like everyone else said, it's a pain to get through to them but they usually respond to customers pushing them for answers. They should cover one detailed anatomy scan in a pregnancy.

Also, it might be worthwhile to double check your plan to see what coverage period is used (calendar year vs fiscal year). Depending on the type of plan you have and the coverage period it uses, you may be stuck paying into your annual deductible which could explain the response from the billing office (but that shouldn't be a flat out denial).

F2M n Spouse

I was being pushy trying to get out of her what exactly I needed for a diagnoses to have the ultrasound covered and she said go to Aetna.com and type in pregnancy ultrasound and it will pop up with what diagnoses I need to have it covered. Well it's pretty vague.
They're trying to use either code 76817 or 76811 for the 20 week ultrasound to be covered. I have no idea what code they used for my 10+5 week ultrasound but I'm assuming it was covered because I was spotting prior to it and if there's spotting or threatened abortion it's covered. I had an ultrasound at 8 weeks and that was covered and 10+5 and I'm assuming that was covered because they didn't mention to me today that it wasn't.
I will call again tomorrow morning and hopefully get some better answers. But I don't know what codes were used for the two ultrasounds.

perry261

I hope your able to get it all worked out!